Initial Comments:Based on the findings of an unannounced onsite state re-licensure and Medicare recertification survey conducted on March 18, 2024 through March 21, 2024, Crozer Keystone 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 onsite state re-licensure and Medicare recertification survey conducted on March 18, 2024 through March 21, 2024, Crozer Keystone 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:
418.56(e)(2) STANDARD
COORDINATION OF SERVICES
Name - Component - 00
[The hospice must develop and maintain a system of communication and integration, in accordance with the hospice's own policies and procedures, to-]
(2) Ensure that the care and services are provided in accordance with the plan of care.
Observations:
Based on review of agency policy, clinical records (CR), and an interview with the agency's administrator, the hospice failed to follow the Hospice Plan of Care and/or Physician orders for eight (8) of nineteen (19) clinical records (CR # 5, 7, 8, 9, 13, 15, 17 and 19).
Findings include:
A review of the agency policy and procedures occurred on 3/21/2024 at approximately 2:00 PM and revealed the following:
Policy titled, "Assessment Documentation" stated, "... D. Confirmed missed visits: missed visit reasons will be documented under visit management and the MD or designee will be notified, if visit is out of the frequency order. Ie. Spoke with Mary from Dr. Hurts office regarding missed visit for xyz reason. E. Confirmed missed visits for HHA: HHA will enter a missed visit note with reason and notify case manager of missed visit. The case manager will notify the MD if visit is out of frequency range..."
A review of clinical records (CR) was conducted on 3/18/2024 from approximately 1:00 PM until 2:30PM, 3/19/2024 from approximately 1:00 PM until 3:00PM, 3/20/2024 from approximately 1:00 PM until 3:15PM, and 3/21/2024 from 10:20 AM to 10:40 AM revealed the following:
CR#5. Start of Care: 12/7/2023. Certification period reviewed: 12/7/2023 - 3/5/2024. File contained Skilled Nursing (SN) orders for three (3) times weekly for twelve (12) weeks. During the week of 1/14/2024 - 1/20/2024, only one (1) SN visit was conducted. There was no documentation that the IDG was notified about the remaining missed visit, and there was no verbal order to update or discontinue the order.
CR#7. Start of Care: 12/18/2023. Certification period reviewed:12/18/2023 - 2/15/2024. File contained SN orders for two (2) times weekly for thirteen (13) weeks. During the week of 1/14/2024 - 1/20/2024, only one (1) SN visit was conducted. There was no documentation that the IDG was notified about the remaining missed visit, and there was no verbal order to update or discontinue the order.
CR#8. Start of Care: 6/9/2023. Certification period reviewed: 6/9/2023 - 9/6/2023. File contained SN orders for three (3) times weekly for twelve (12) weeks. During the week of 7/23/23 - 7/29/23, only one (1) SN visit was conducted. File contained physical therapy (PT) orders for two (2) times weekly for four (4) weeks. During the weeks of 6/25/23 - 7/1/24, only one (1) PT visit was conducted. During the week of 7/2/24 - 7/8/24, no PT visit was conducted. There was no documentation that the IDG was notified about the remaining missed visit, and there was no verbal order to update or discontinue the order.
CR#9. Start of Care: 10/28/23. Certification period reviewed: 10/28/23 - 1/25/24. File contained SN orders for two (2) times weekly for thirteen (13) weeks. During the weeks of 11/19/23 - 11/25/23, 12/10/23 - 12/16/23 and 12/31/23 - 1/6/24, only one (1) SN visit was conducted each week. There was no documentation that the IDG was notified about the remaining missed visit, and there was no verbal order to update or discontinue the order.
CR#13. Start of Care: 7/21/23. Certification period reviewed: 7/21/23 - 10/18/23. File contained SN orders for two (2) times weekly for thirteen (13) weeks. During the week of 8/6/23 - 8/12/23, only one (1) SN visit was conducted. There was no documentation that the IDG was notified about the remaining missed visit, and there was no verbal order to update or discontinue the order.
CR#15. Start of Care: 3/8/23. Certification period reviewed: 3/8/23 - 4/28/23. File contained Hospice Aide (HA) orders for three (3) times weekly for thirteen (13) weeks. During the week of 3/5/23 - 3/11/23, only two (2) HA visits were conducted. There was no documentation that the IDG was notified about the remaining missed visit, and there was no verbal order to update or discontinue the order.
CR#17. Start of Care: 2/14/23. Certification period reviewed: 2/14/24 - 5/13/24. File contained Chaplain orders for one (1) time between 2/13/24 to 2/18/24. During 2/13/24 - 2/18/24, no Chaplain visit was conducted. There was no documentation that the IDG was notified about the remaining missed visit, and there was no verbal order to update or discontinue the order.
CR#19. Start of Care: 11/20/23. Certification period reviewed: 11/20/23 - 2/17/24. File contained SN orders for two (2) time weekly for thirteen (13) weeks. During week of 12/10/23 - 12/16/23, only one (1) SN visit was conducted. There was no documentation that the IDG was notified about the remaining missed visit, and there was no verbal order to update or discontinue the order.
An interview with the Hospice's administrator on 3/21/2024 at approximately 3:00 PM confirmed the above findings.
Plan of Correction:Agency will provide written copy of and re-education on the Policy entitled "Assessment Documentation" which will reinforce the procedure to be followed for missed visits. All staff members will sign off on receiving the Policy and the re-education.
This will be completed by 4/3/2024
Agency will conduct monthly audits of patient records to assure corrective action is sustained with frequency orders and missed visit documentation and communication with the IDT.
Monitoring will occur for a timeframe of at least three (3) months and until 90% compliance is obtained.
This will begin 4/3/2024.
End date is 3 months or 90% compliance whuchever occurs first.
Initial Comments:Based on the findings of an unannounced onsite state re-licensure and Medicare recertification survey conducted on March 18, 2024 through March 21, 2024, Crozer Keystone 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 onsite state re-licensure and Medicare recertification survey conducted on March 18, 2024 through March 21, 2024, Crozer Keystone Hospice was found to be in compliance with the requirements of 35 P.S. § 448.809 (b).
Plan of Correction:
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