QA Investigation Results

Pennsylvania Department of Health
CROSSINGS HOSPICE OF THE VNA
Health Inspection Results
CROSSINGS HOSPICE OF THE VNA
Health Inspection Results For:


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Initial Comments:


Based on an unannounced on site hospice Medicare recertification survey conducted between 3/26/2021-3/29/2021, Crossings Hospice of the VNA, 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 an unannounced on site hospice Medicare recertification and state re-licensure survey conducted between 3/26/2021-3/29/2021, Crossings Hospice of the VNA, was found to be not in compliance with the requirements of 42 CFR, Part 418, Subparts A, C, and D, Conditions of Participation: Hospice Care.











Plan of Correction:




418.54(b) STANDARD
TIMEFRAME FOR COMPLETION OF ASSESSMENT

Name - Component - 00
The hospice interdisciplinary group, in consultation with the individual's attending physician (if any), must complete the comprehensive assessment no later than 5 calendar days after the election of hospice care in accordance with 418.24.



Observations:


Based upon review of agency policy, medical records (MR), Hospice Interdisciplinary Group (IDG) minutes, and interview with supervising nurse ( EMP # 1), agency failed to show evidence Interdisciplinary group (IDG) in consultation with physician, completed comprehensive assessment within 5 days after election of hospice for four (4) of four (4) records reviewed ( MR # 1-4).

Findings included:

Review of agency policy on 3/29/2021 between approximately 12:30 PM-2:30 PM titled " Initial and Comprehensive Assessment of the patient" stated " (1) to be completed by the hospice interdisciplinary group (IDG) in consultation with the attending physician. (2) to be completed within five (5) calendar days after the election of Hospice care from is signed by the patient/representative"


Review of MR on 3/26/2021 between approximately 9:15 AM-11:00 AM and 3/299/2021 between approximately 9:00 AM-12:00 PM revealed:

MR # 1, Start of Care (SOC) 3/20/2020; certification period 3/20/2020-6/17/2020, Primary Diagnosis: Alzheimer's disease.

Review of IDG meeting minutes on 3/31/2020 indicated initial discussion of MR # 1. Comments from IDG meeting: " Alert and oriented, some forgetfulness. Arm circumference 35 cm. Appetite fair, eating 2 meals per day. Denies nausea 0/10. Pain 0/10, pain maintained with heating pad as needed. Pressure ulcer to right buttock, 0.5 cm x 0.2 cm x 0. 1cm smal serous drainage, no odor, wound bed prink surrounding skin intact. ..."
This discussion occurred eleven (11) days after patient signed benefit election on 3/20/2020.


MR # 2, SOC 3/17/2020; certification period 3/17/2020-6/14/2020, Primary Diagnosis: Malignant Neoplasm of unsp. \ part of bronchus of lung, Chronic Obstructive Pulmonary Disease (COPD) of IDG meeting minutes on 3/31/2020 indicated initial discussion of MR # 2.
Comments from IDG meeting: transferred to another hospice 3/23/22020."
This discussion occurred fourteen (14) days after patient signed benefit election on 3/17/2020.


MR # 3, SOC 8/12/2020; certification period 8/12/2020-11/9/2020, Primary Diagnosis: Multiple Sclerosis Pressure Ulcer \ of left hip, stage 4, pressure ulcer of left buttock, stage 4, pressure ulcer of right hip, stage 4, pressure ulcer of right buttock, stage 4.."

Review of IDG meeting minutes on 8/19/2020 indicated initial discussion of MR # 3.
Comments from IDG meeting: 8/19/2020." no comments "
This discussion occurred seven (7) days after patient signed benefit election on 8/12/2020.

MR # 4, SOC 8/26/2020; certification period 8/26/2020-11/23/2020, Primary Diagnosis:
Trauma sub hem with/out loss of consciousness essential hypertension of IDG meeting minutes on 9/1/2020 indicated initial discussion of MR # 4.
Comments from IDG meeting 9/1/2020 " no comments"
This discussion occurred seven (7) days after patient signed benefit election on 8/26/2020.


Interview with supervising nurse on 3/29/2021 between approximately 2:00 PM-3:00 PM confirmed above findings.














Plan of Correction:

418.54(b) L0523
Education will be given to all hospice staff (including IDG team participants) on the need for collaboration/consultation with all members of the IDG team and the patient's attending physician within five days from the initial date the election of hospice benefits is signed by the patient. This will include the process of communicating to all involved of the hospice admission and necessary information and needs for the patient's plan of care. This education will be complete by April 20th, 2021 and completed by the hospice director and/or designee.
Following the completion of the initial comprehensive assessment, the physician referral document will be updated by the assessing clinician and then sent to all members of the IDG team and the patient's attending physician for any input into the patient's needs and plan of care. This will be completed within two days from start of care with communication with all members of the IDG team/attending physician within 5 days of initial assessment. This will begin with all new admissions beginning April 20th, 2021.
After completion of consultation with all involved, documentation will be added to the patient's plan of care signifying all members of the IDG team, along with the attending physician was consulted regarding the patient's needs within the five-day window.
The hospice director or designee will review documentation following a hospice admission for the next six months to assure the above communication/consultation and documentation is completed in the patient's medical record.
After six months, if all admissions found to be compliant, for the next six months, spot-checking of this documentation will continue. Following one year, if all found to be compliant, the follow-up reviews will be able to stop with the initial plan of correction continuing indefinitely.




418.60(a) STANDARD
PREVENTION

Name - Component - 00
The hospice must follow accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions.


Observations:


Based upon review of agency policy, personnel files (PF), home visits, and interview with supervising nurse ( EMP # 1), agency failed to show evidence infection control measures were followed for therrmometer usage for one (1) home visit observed. (observation # 1of 1)(EMP #2).

Findings included:

Review of agency policy on 3/29/2021 between approximately 12:30 PM-2:30 PM titled " Bag Technique" stated " (4.) Items removed from the bag that are not disposable must be disinfected prior to placing the equipment back into the bag"


Review of PF on 3/26/2021 between approximately 12:00 PM-1:00 PM revealed:

EMP # 2, Date of Hire (DOH) 11/20/2018.

Observation during home visit conducted on 3/29/2021 between approximately 9:15 AM-10:15 AM EMP # 2 had taken MR # 1 temperature by sliding the instrument across the patient's forehead and then placed the thermometer back into her bag without cleaning off the thermometer.

Interview with supervising nurse on 3/29/2021 between approximately 2:00 PM-3:00 PM confirmed above findings.
















Plan of Correction:

Education to all staff will be performed regarding bag technique and the need to follow infection control policies/procedures with all equipment used. This will be completed by the Hospice Director or designee by April 20th, 2021.
The bag technique policy/procedure will be reviewed by all staff by April 20th, 2021.
The bag technique test will be completed by staff by May 1, 2021.
A review will be completed by the hospice director or designee with the hospice nursing staff on proper bag technique with the staff showing proper placement of bag in home, removal of equipment, cleaning of equipment and replacing of equipment. This will be completed by May 10th, 2021.
If any issues found at this time, bag technique will be reviewed with staff.
Consistent review of bag technique and infection control technique will continue with yearly regulatory proficiency/infection control education.



418.100(g)(1) STANDARD
TRAINING

Name - Component - 00
(1) A hospice must provide orientation about the hospice philosophy to all employees and contracted staff who have patient and family contact.


Observations:


Based upon review of agency policy, personnel files (PF), and interview with supervising nurse ( EMP # 1), agency failed to show evidence employees were oriented to hospice philosophy for two (2) of six (6) files reviewed. (PF # 2, PF # 5).

Findings included:

Request for agency policy on 3/29/2021 between approximately 12:30 PM-2:30 PM produced no policy.

Review of PF on 3/26/2021 between approximately 12:00 PM-1:00 PM revealed:

PF # 2, Date of Hire (DOH) 3/23/2020; no documentation orientation to hospice was given.

PF # 5, DOH 1/26/2018; no documentation orientation to hospice was given.

Interview with supervising nurse on 3/29/2021 between approximately 2:00 PM-3:00 PM confirmed above findings.










Plan of Correction:

Orientation on the hospice philosophy to all employees who have patient and family contact will be reviewed with all necessary personnel by April 20th, 2021. This will include all members of the IDG team. An attestation from all necessary personnel will be signed and dated and placed in their personnel records. This will be completed by May 1st, 2021.
As new staff and new members of the IDG team come on board, this education with attestation statement will continue indefinitely.
The attestation will include the ability to contact the hospice director or designee for any questions on concerns or for further education.
The HR Director or designee will check all new hires for this information attestation statement before filing in HR records to assure complete. This will continue indefinitely.




Initial Comments:


Based on an unannounced on site hospice Medicare recertification and state re-licensure survey conducted between 3/26/2021-3/29/2021, Crossings Hospice of the VNA, 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 upon an unannounced on site hospice Medicare recertification and state re-licensure survey conducted between 3/26/2021-3/29/2021, Crossings Hospice of the VNA, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).










Plan of Correction: