QA Investigation Results

Pennsylvania Department of Health
AMEDISYS HOSPICE OF PA
Health Inspection Results
AMEDISYS HOSPICE OF PA
Health Inspection Results For:


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Initial Comments:Based on the findings of an onsite complaint investigation survey completed December 16, 2022, Amedisys 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(c)(1) STANDARD
RIGHTS OF THE PATIENT

Name - Component - 00
The patient has a right to the following:
(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), Agency Policy and Procedure, and employee (EMP) interviews, the agency failed to ensure management of wounds for five (3) of three (3) CR's reviewed (CR1-3.) Findings included: Review of agency policy on 12/14/2022 at approximately 1:00pm revealed: "...The Provision of Wound and Skin Care" ...GENERAL GUIDANCE: ... Measuring ... In accordance with best practice and standard of care, wounds will be measures a minimum of one time a week, preferably on the first visit of the week, by the same nurse, utilizing the same tool and measurement terminology. The preferred day for measuring is the first visit of each week ..." Review of CR conducted 2/14/2022 between approximately 11:00am and 1:30 pm and 12/15/2022 revealed: CR1, Start of Care (SOC) 8/1/2022, benefit period reviewed 8/1/1011-10/27/2022. Following wounds identified, CR failed to include evidence of wound measurements per agency policy. Coccyx pressure ulcer, present on SOC 8/1/2022: Skilled Nursing visit documentation on 9/13/2022, “Wound Record Report …Wound Details…9/13/2022 5:11PM…Measurements Taken NO…Reason Measurements Not Taken NOT DUE…” Skilled Nursing visit documentation on 10/11/2022, “Wound Record Report …Wound Details…10/11/2022 3:08PM…Measurements Taken NO…Reason Measurements Not Taken NOT DUE…” Skilled Nursing visit documentation on 10/23/2022, “Wound Record Report …Wound Details…10/23/2022 1:05PM…Measurements Taken NO…Reason Measurements Not Taken NOT DUE…” Left axillary abscess, onset 8/24/2022: Skilled Nursing visit documentation on 9/13/2022, “Wound Record Report …Wound Details…9/13/2022 5:11PM…Measurements Taken NO…Reason Measurements Not Taken NOT DUE…” Left heel blister, onset 10/18/2022: Skilled Nursing visit documentation on 10/23/2022, “Wound Record Report …Wound Details…10/23/2022 1:05PM…Measurements Taken NO…Reason Measurements Not Taken NOT DUE…” Sacral wound/deep tissue injury, onset 10/21/2022: Skilled Nursing visit documentation on 10/23/2022, “Wound Record Report …Wound Details…10/23/2022 1:05PM…Measurements Taken NO…Reason Measurements Not Taken NOT DUE…” Skilled Nursing visit documentation 11/25/2022 read, ..."wound noted to left arm..." No evidence of wound assessment or measurements obtained. CR 2, SOC 11/17/22, benefit period reviewed 11/17/22-2/14/22. Following wounds identified, CR failed to include evidence of wound measurements per agency policy. Skilled Nursing visit documentation on 11/17/2022, “Visit Note Report …Wound Assessment…Male Posterior…#3 – COCCYX, PU (Pressure Ulcer) Stage II – HCHB…Onset date: 1/17/2022…Wound Assessed YES…Measurements Taken NO…Reason Measurements not taken…REFUSED…” Skilled Nursing visit documentation on 11/22/2022, “Wound Record Report …Wound Details…11/22/2022 1:26 PM…Measurements Taken NO…Reason Measurements Not Taken NOT DUE…” Skilled Nursing visit documentation on 11/28/2022, “Wound Record Report …Wound Details…11/28/2022 11:41 AM…Measurements Taken NO…Reason Measurements Not Taken NOT DUE…” Skilled Nursing visit Documentation on 12/13/2022, “Wound Record Report …Wound Details…12/13/2022 10:15 AM…Measurements Taken NO…Reason Measurements Not Taken NOT DUE…” CR 3, SOC 10/8/2022, benefit periods reviewed10/8/2022-12/6/2022 and 12/7/22-2/4/23. Following wounds identified, CR failed to include evidence of wound measurements per agency policy. Skilled Nursing visit documentation on 12/5/2022, “Visit Note Report …Wound Assessment…Male Posterior…#2 – LT – LOW BUTTOCK, LT, PU (Pressure Ulcer) STAGE II [INACTIVATED 11/04/2022], [REACTIVATED 11/29/2022] – HCHB…Onset date: 10/28/2022…Wound Assessed NO, CAREGIVER COMPLETED CARE…” Skilled Nursing visit documentation on 12/13/2022, Certification Period 12/7/2022 – 2/4/2023, “Visit Note Report …Wound Assessment…Male Posterior…#2 – LT – LOW BUTTOCK, LT, PU STAGE II [INACTIVATED 11/04/2022], [REACTIVATED 11/29/2022] – HCHB…Onset date: 10/28/2022…Wound Assessed YES…Measurements taken NO…Reason Measurements not taken NOT DUE…” Exit interview conducted on December 16, 2022, at approximately 10:00am with Clinical Director, Area vice President of Clinical, and Area Vice President of Operations confirmed findings.

Plan of Correction:

L0512:418.52 (c) Rights of the Patient
1. On 12/16/22 - upon notification of areas of deficiencies, the Administrator/Director of Operations with the assistance of the Area Vice President of Operations/Clinical implemented comprehensive and systematic changes to ensure ALL current patients and future patients received care and services based on an accurate comprehensive assessment of the patients and family's needs in accordance with federal and state regulations; agency policies and procedures; and standards of practice. Also the Administrator/Director of Operations and Assistant Vice President of Operations/Clinical implemented measures to ensure identified deficiencies would not reoccur as evidenced by education and training (active nursing staff, medical director and nurse practitioner); reassessment requirements of patient's with wounds, pain and other symptoms; development and monitoring of a patient-specific plan of care; appropriate plan of care updates with physician/Interdisciplinary group (IDG) overview and appropriate coordination of care; skilled competency assessments field visits with active nursing staff and ongoing auditing of medical records as detailed below. On 12/19/22, the Administrator/Director of Operations and the Area Vice President of Operations and Area Vice President of Clinical Operations provided:
a. Education/Training - Initiated 12/19/22 Comprehensive re-education and remediation for ALL active nursing staff on applicable agency policies related to deficient areas:
- Review of Agency Policies and Procedures:
o AA-003 Assessments,
o AA-005 Hospice Plan of care,
o MM-003 Pain and Symptom Management
o WC-001 Wound Care References and Resources,
o WC-007 Assessment Staging of Pressure Injuries,
o WC-009 Management Prevention of Pressure Injuries, and
o Tx-005 Professional Management

- Course Assignments:
o Hospice Palliative Wound Care
o Pressure Ulcers

b. Identification/Implementation Initiated on 12/19/22, identification of ALL active patients with documented and reported alterations in skin integrity for reassessment, appropriate interventions, coordination of care and an individualized patient-specific plan of care update for wound and pain management by utilizing 100% medical review and interviews with nursing staff.
- ALL patients identified with impaired skin integrity received a comprehensive skilled nurse assessment visit inclusive identification of risk for alterations in skin integrity/preventive measures; alterations in skin integrity/wound management - wound location, stage, description/ measurement; pain associated with wounds; current treatment order and appropriate documentation in current plan of care.
- ALL patients received the appropriate revision to the plan of care reflected as 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.
- On 12/19/22the Administrator/Director of Operations implemented process to ensure ALL active nursing staff received ongoing education/training on agency policies and procedures, documentation requirements, onsite competency assessment field visits utilizing agency competency skilled checklist. Ongoing, the Administrator/Director of Operations and designees will ensure appropriate training for newly hired nurse's, skilled competency completed and staff remediation as needed.

c. Ongoing education/training and monitoring was implemented as follows:
- On 12/29/22 ALL active nursing staff received additional virtual training of wound management documentation by the corporate virtual trainer and registered nurse certified by the Wound, Ostomy and Continence Certified Nurses Society (WOCN)
- On 12/19/22 the Administrator/Director of Operations and designees initiated the following to ensure ongoing compliance:
o A comprehensive auditing process of clinical documentation of 100% of current and newly admitted patients to ensure the completion of:
a. Patient-specific and accurate comprehensive assessment in accordance with federal and state regulations, agency policies and procedures, and industry standards of care as evidenced by ongoing assessment of identified risks and preventive measures; identification of alterations in skin integrity; consistency and accuracy of documentation based on patient's condition, orders and measurable goals.
b. Development, adherence, and ongoing evaluation with appropriate revision to the patient-specific plan of care in accordance with the patient's current condition/needs and agency's policies and procedures; including responsible provider performance of agreed upon repetitive functions; and including measurable goals and outcomes in coordination/ oversight of the patient's physician/Interdisciplinary Team.
c. Appropriate and ongoing coordination of care with all disciplines and nursing facility (as applicable) as well as the patient/patient caregiver (to the extent possible).
d. Appropriate delivery of care and interventions provided based on plan of care and patient's needs.
o Auditing to continue weekly for a period of 3 months or until a minimum of 100% compliance is met. Ongoing, 25% of the wound care patients will be audited quarterly thereafter with staff remediation including reeducation and skills competency assessments as needed when problems are identified.
o All findings will be reported at the quarterly QAPI committee meeting and Governing Body as appropriately, but at least annually.
- By 2/3/22 DOO/designee will schedule a follow-up on-site skilled nursing competency assessment field visits of ALL active nursing staff to ensure ongoing competency and adherence to the plan of care, as well as agency policies and procedures which was completed on 12/19/22
d. The Administrator/Director of Operations will ensure ongoing adherence and monitoring of all aspects of the plan of corrections for cited deficiencies.







418.56 STANDARD
IDG, CARE PLANNING, COORDINATION OF SERVICES

Name - Component - 00
The plan of care must specify the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions.


Observations: Based on review of Clinical Records (CR), Agency Policy and Procedure, and employee (EMP) interviews, the agency failed to ensure preventative equipment provided based on comprehensive assessment for one (1) of three (3) CR's reviewed (CR1.) Findings included: Review of agency policy on 12/14/2022 at approximately 1:00pm revealed: "...Other Services - Medical Supplies and Equipment...Policy: Medical supplies and equipment including medications identified in the POC and related to the palliation and management of the patient's terminal diagnosis and related conditions will be provided by the hospice..." Review of CR conducted 2/14/2022 between approximately 11:00am and 1:30 pm and 12/15/2022 revealed: CR1, Start of Care (SOC) 8/1/2022, benefit period reviewed 8/1/1011-10/27/2022. initial comprehensive assessment conducted 8/1/2022 identified patient to be "high risk" of developing pressure ulcers due to immobility, poor nutrition, and incontinence. Patient documented to have pressure ulcer present on coccyx. No evidence agency implemented pressure relieving equipment based upon risk assessment and current patient condition. Exit interview conducted on December 16, 2022, at approximately 10:00am with Clinical Director, Area vice President of Clinical, and Area Vice President of Operations confirmed findings.

Plan of Correction:

L0538: 418.56 IDG, Care Planning, Coordination of Services
As described in more detail below, Amedisys Hospice has implemented corrective actions aimed at reinforcing its policies and practices for developing and implementing individualized written plans of care, established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or his/her representative, and the primary care giver, in accordance with the patient's needs.

1. Corrective Action / Preventing Reoccurrence: On 12/19/2022, upon notification of areas of deficiencies, the Administrator/Director of Operations, with the assistance of the Area Vice President of Operations, implemented comprehensive and systematic changes to ensure that: (A) ALL current patients and future patients receive care and services based on an accurate, comprehensive assessment of each patient's and family's needs in accordance with federal and state regulations; agency policies and procedures; and standards of practice in regard to providing 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 care giver in accordance with patient needs if any of them so desire.; (B)ALL current patients and future patients receive care and services based on an accurate comprehensive assessment of each patient's and family's needs in accordance with federal and state regulations; agency policies and procedures; and standards of practice in regard to ensuring the individualized plan of care captures interventions to manage pain and symptoms and reporting to the attending physician and hospice medical director if pain is not within an acceptable level as established by patient or his/her decision-maker with collaboration with the hospice medical director and interdisciplinary group.

a. Education/Training: On 12/27/2022 the Administrator/Director of Operations, Area Vice President of Clinical Operations and Area Vice President of Operations provided: Comprehensive re-education and remediation for the development of an individualized plan of care per agency policies related to deficient areas:
- Review of Agency Policies and Procedures:
o AA-003 Assessments,
o AA-005 Hospice Plan of care,
o AA-006 Interdisciplinary Team,
o Tx-005 Professional Management
o TX- 012 Core Services Nursing Services
o MM-003 Pain and symptom management
o AA-001 Admission
o EC-003 Medication equipment management and calibration

b. Implementation & Monitoring: Initiated on 12/27/2022 to ensure the compliance with individualize pain management and oversight of plan of care requirements, 25% of patient charts shall be audited weekly to ensure 100% compliance for acceptable pain levels in each individualized plan of care as well as proper equipment and interventions in place for comfort. First 25% will be completed by 12/30/2022 until 100% compliance has been achieved. All new admissions will be audited weekly until 100% compliance is maintained for four (4) weeks. Then, an audit will be completed of 10% of new admissions monthly until 100% compliance has been maintained for two (2) consecutive quarters.

c. Person Responsible. The Administrator/Director of Operations is responsible for confirming the above requirements are met and documented. All findings will be reported at the quarterly QAPI committee meeting, as well as to the Governing Body as appropriate, but at least annually.

d. Completion Date: 2/3/2023.