Initial Comments:
Based on the findings of an onsite unannounced complaint investigation and Medicare recertification survey completed February 5, 2024, Good Samaritan Hospice of Pittsburgh 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 onsite unannounced complaint investigation and Medicare recertification survey completed February 24, 2024, Good Samaritan of Pittsburgh was found not to be in compliance with the following requirements of 42 CFR, Part 418, Subparts A, C, and D, Conditions of Participation: Hospice Care.
Plan of Correction:
418.52(c)(2) STANDARD
RIGHTS OF THE PATIENT
Name - Component - 00
[The patient has a right to the following:]
(2) Be involved in developing his or her hospice plan of care;
Observations:
Based on review of agency policy and a clinical record (CR), and staff (EMP) interview, the agency failed to protect and promote the rights of the patient and family for one (1) of one (1) clinical record reviewed with an advance directive and discharged (revoked) from the Beaver inpatient unit (CR1).
Review of agency policy on February 2, 2024, at 12 p.m. showed:
"Subject: Patient Rights and Responsibilities Policy 11.1 Policy Statement: ... the hospice must protect and promote the exercise of these rights. ... Procedures: 1. Patient Rights The following rights are to be respected by all Good Samaritan employees and integrated into all hospice agency functions. ... Have your family or guardian exercise your rights when or if you may be judged incompetent ... Be involved in ... developing and participating in your hospice plan of care; including transfer to another hospice, and changes in level of care as condition warrants ... Be informed of anticipated discharge or transfer of care/service, continuing care requirements and other available services."
"Subject: Advance Directives Policy 11.5 ... Definition ... Advance health care directive-The term as defined in 20 Pa.C.S. 5422 (relating to definitions). An advance health care directive is a signed and witnessed document which directs health care in the event that the individual (the principal) is incompetent and has an end-stage medical condition or is permanently unconscious. It also may designate a person to carry out the individual's wishes regarding health care at the end of life. ... Purpose: To provide an opportunity to educate patients/family about their right to be involved in decisions regarding their care including documentation of advance directives and allowance of the patient's representative to facilitate care or make treatment decisions when the patient is unable to do so."
A review of CR1 on January 31, 2024, at 8 a.m. showed a physician ordered plan of care with an initial certification period from 12/12/2023 to 3/10/2024. The patient was admitted to the agency's Beaver Valley inpatient unit (IPU) on 12/12/2023 with sepsis and altered mental status. According to the "RN HOSPICE IPU ADMISSION VISIT" completed on 12/12/2023, the patient had a "POA [power of attorney] AND LIVING WILL," and "WILL OPEN EYES, BUT IS MINIMALLY RESPONSIVE." On 12/13/2023, the patient was unresponsive. A review of patient's "DURABLE HEALTH CARE POWER OF ATTORNEY" showed the patient had appointed his/her granddaughter (DTR1) to server as his/her successor. The POA also indicated that if DTR1 was not readily available, then his/her other granddaughter (DTR2) would serve as his/her successor. Review of "Patient Contacts" contained within CR1 showed DTR1 was listed as the patient's power of attorney. A review of CR1's hospice "Election of Benefit" showed that DTR1 elected the hospice benefit on 12/12/2023 due to pt's mental incapacitation. Review of registered nurse note from 12/12/2023 showed, "Spoke with both granddaughters ([DTR1] first POA [DTR2] second). ... [DTR1] resides in South Carolina and is available by phone 24/7."
Review of "Client Coordination Note Report" from 12/15/2023 showed the social worker documented, "Pt's granddaughter [DTR2] wants to take pt back to [personal care home] to pass there on [another hospice agency]. ... [DTR2] understands all of the risk and everything discussed if transport can accommodate today SW [social worker] will make arrangements to send back to [personal care home] tonight."
Review of "Hospice Revocation Statement Form" showed that DTR2 revoked CR1's hospice benefit on 12/16/2023. Further review of CR1 did not show that DTR1 wished to revoke CR1's hospice benefit or that DTR1 was notified that DTR2 wanted to revoke the patient's hospice benefit. There was nothing in CR1 to show that DTR1 was not readily available.
Interviews with EMP1 (administrator) and EMP2 (director of compliance) on February 5, 2024, at 12 p.m. confirmed above findings.
Plan of Correction:How will the agency correct the deficiency?
- Education provided to all Beaver in-patient unit staff on Policy 11.5 – Advance Directives as well as Policy 11.1 – Patient's Rights and Responsibilities and remind staff that they must be following policies.
Measures or systems the Agency will alter to ensure the problem does not occur:
- Education provided to all Beaver in-patient unit staff on Policy 11.5 – Advance Directives as well as Policy 11.1 – Patient's Rights and Responsibilities.
- Education provided to all Beaver in-patient unit staff on documenting appropriate relationship to patient in patient's electronic health record (EHR).
Plans to monitor the Agency's performance to ensure the problem does not occur:
- Weekly audits of 5 patients per week for 4 weeks to verify that a copy of the patient's advance directive (if they have one) is on the patients' EHR. Then 10 charts per quarter will be audited to monitor continued compliance. Any chart reviewed that is inaccurate will have follow up with the clinician for re-education and individual remediation. Auditing to be completed by clinical leadership or designee and will begin 3/4/2024
418.56(c)(3) STANDARD
CONTENT OF PLAN OF CARE
Name - Component - 00
[The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following:]
(3) Measurable outcomes anticipated from implementing and coordinating the plan of care.
Observations:
Based on review of agency policy and clinical records (CR), and staff (EMP), the agency failed to implement a plan of care with measurable outcomes for four (4) of 21 records with goals for pain (CR19, CR20, CR21, &; CR25).
Review of agency policy on February 2, 2024, at 12 p.m. showed, "Subject: Plan of Care Policy 9.4 ... Policy Statement: All hospice care and services provided to patients/families must follow an individualized written plan of care. Purpose: To include and address all services necessary for the palliation and management of the terminal illness and related conditions. Procedures: ... 2. Content Plan of Care a. The plan of care must include documentation of the following: ... Measurable outcomes anticipated from implementing and coordinating the plan of care."
Review of CR19 on 1/31/2024 at 2 p.m. showed a plan of care for an initial certification period from 12/20/2023 to 3/18/2024. Goals included, "Pain will be managed at a level acceptable to [CR19] while on hospice services." A review of the start of care and subsequent visit notes showed that on 12/20/2023 CR19 was "nonresponsive" and on 12/21/2023 CR1 was "unable to respond." Patient was not able to state his/her acceptable level of pain.
Review of CR20 on 1/31/2024 at 2:30 p.m. showed a plan of care for an initial certification period from 10/18/2023 to 1/15/2024. Goals included, "Pain will be managed at a level acceptable to [CR20]." A review of the start of care visit note by registered nurse from 10/18/2022 did not show that the patient stated what his/her acceptable level of pain was. On 10/21/2023, the registered nurse documented patient was, "Lethargic" with "no verbal communication."
Review of CR21 on 1/31/2024 at 3 p.m. showed a plan of care for an initial certification period from 11/3/2023 to 1/31/2024. Goals included, "Pain will be managed at a level acceptable to [CR21]." A review of the start of care visit note from 11/3/2023 did not show that the patient rated his/her acceptable level of pain. On 11/4/2023, the licensed practical nurse documented that the patient was "bedbound" and "unresponsive." The patient expired on 11/5/2023 and according to the "Hospice POC Report," the goal of "Pain will be managed at a level acceptable to [CR21]" was "MET." Patient was not able to state his/her acceptable level of pain.
Review of CR25 on 2/2/204 at 1:30 p.m. showed a plan of care for an initial certification period from 1/21/2024 to 4/19/2024. Goals included, "Pain will be managed at a level acceptable to [CR25] while on IPU [inpatient unit]." Review of start of care visit note by the registered nurse from 1/21/2024 showed patient as oriented to self only and minimally verbal. There was no documentation from this visit to show what patient's acceptable level of pain was. Subsequent nursing visit note from 1/22/2024 showed patient was "Unable to respond."
Interviews with EMP1 (administrator) and EMP2 (director of compliance) on February 5, 2024, at 12 p.m. confirmed above findings.
Plan of Correction:How will the agency will correct the deficiency?
- Measurable goals for CR19, CR20, CR21, and CR25 could not be updated as these patients have already ceased to breathe.
- Plan of care development process for unresponsive patients has been revised.
Measures or systems the Agency will alter to ensure the problem does not occur:
- Education will be provided to all in-patient unit staff on how to appropriately create measurable outcomes and goals associated with the plan or care.
- Education will be provided to all in-patient staff on Policy 9.4 – Plan of Care Policy
Plans to monitor the Agency's performance to ensure the problem does not occur:
- Weekly audits of 5 patients per week for 4 weeks to verify appropriate and measurable goals are on the plan of care. Then 10 charts per quarter will be audited to monitor continued compliance. Any chart reviewed that is inaccurate will have follow up with the clinician for re-education and individual remediation. Auditing to be completed by clinical leadership or designee and will begin 3/4/2024
418.58(a)(2) STANDARD
PROGRAM SCOPE
Name - Component - 00
(2) The hospice must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations.
Observations:
Based on review of agency policy, infection logs, meeting minutes, quality assessment and performance improvement (QAPI) data, and staff (EMP) interview, the agency failed to measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the hospice to assess processes of care, hospice services and operations for 17 patients and 18 employees diagnosed with covid-19 since August 1, 2023.
Review of agency policy on February 2, 2024, at 12 p.m. showed, "Subject: Infection Control Program Policy 7.11 Policy Statement: Good Samaritan Hospice maintains and documents an infection control program. Purpose: An effective infection control program protects patients, families, visitors, and hospice personnel by preventing and controlling infections and communicable diseases. Procedures: ... 3. Reporting a. The identifying clinician or agency representative is responsible for completing a QI report. b. The QI reports are reviewed and processed by the agency designee. 4. Tracking/Trending a. The agency's Quality and/or Compliance representative is responsible for tracking and trending all reported infections. Some of the information tracked includes: Type of infection ... Branch location ... Interventions ... Contributing factors ... Number of infections per 1000 patient days b. Infections are aggregated quarterly and reported to the Compliance Committee as part of the QAPI program."
A review of "QI Event Report" infection logs was conducted February 2, 2024, at 1:30 p.m. The logs listed patient infections since 8/1/2023. There were no covid-19 infections listed. Review of QAPI meeting minutes on February 2, 2024, at 2 p.m. showed, "Good Samaritan Hospice Compliance Committee Date: August 4, 2023 ... Education &; Training The following education had been provided for staff: Effective June 2023, COVID is No longer reportable to Department of Health for 'Reportable Diseases'." The "Good Samaritan Hospice Compliance Committee Date: November 3, 2023" minutes were also reviewed. There was nothing contained in the QAPI documentation to show that the agency measured, analyzed, and tracked patient and employee covid-19 infections.
During interview with EMP2 (compliance director) on February 5, 2024, at 11:50 a.m. he/she confirmed that the agency has not been tracking or analyzing covid-19 positives since 8/1/2023, "No longer a health department reportable disease." He/she noted that he/she kept employee covid-19 positives in a small notebook but that they weren't counted. EMP1 (administrator), EMP2, and EMP8 (IT) took several minutes to review several different systems within their EMR (electronic medical record), patient infection logs, and EMP2's handwritten notebook before a covid-19 positive count was obtained for 18 employees and 17 patients.
Plan of Correction:How will the agency will correct the deficiency?
- The Agency will continue to log all patient infections, including COVID infections, into an infection occurrence report in the EHR.
- The Agency will continue to track and trend each infection and will report on them during the quarterly compliance committee meeting
Measures or systems the Agency will alter to ensure the problem does not occur:
- The Agency was tracking/trending of employee COVID infections on a paper log. The Agency created a shared spreadsheet with employee specific infections for better tracking and reporting purposes.
- The Agency will continue to track and trend each infection (both patient and employee) and will report during the quarterly compliance meeting
- Education will be provided to the clinical management team on Policy 7.11 Infection Control plan as well as the process for appropriate reporting of all infections.
- Education will be provided to the clinical management team on appropriate reporting of these infections to the Department of Health through the Event Reporting System (ERS)
Plans to monitor the Agency's performance to ensure the problem does not occur:
- Weekly audits will be completed on 5 patient and/or employee records to verify if the patient or employee had developed an infection that the infection was entered in an occurrence report following proper agency protocol and reported to the Department of Health ERS when necessary. Then, 10 records per quarter will be audited to monitor continued compliance. Any record reviewed that is inaccurate will have follow up with the responsible employee for re-education and individual remediation. Auditing to be completed by clinical leadership or designee and will begin 3/4/2024
418.110(k) STANDARD
Sanitary environment
Name - Component - 00
§418.110(k) Standard: Sanitary environment.
The hospice must provide a sanitary environment by following current standards of practice, including nationally recognized infection control precautions, and avoid sources and transmission of infections and communicable diseases.
Observations:
Based on review of agency policy, manufacturer's directions for use, standards of practice, observations, and staff (EMP) interview, the agency failed maintain a sanitary environment and follow accepted standards of practice for one (1) of two (2) inpatient units (Beaver Valley).
Review of agency policy on February 2, 2024, at 12 p.m. showed, "Subject: Infection Control Program Policy 7.11 Policy Statement: Good Samaritan Hospice maintains and documents an infection control program. Purpose: An effective infection control program protects patients, families, visitors, and hospice personnel by preventing and controlling infections and communicable diseases. Procedures: 1. Responsibility The agency's Quality and/or Compliance representative is responsible for the Infection Control Program. ... 5. Accepted Standards of Practice ... Examples of best practice standards used to prevent the transmission of infections and communicable diseases include: ... Standard Precautions are indicated for all patients. Standard precautions are based on the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents. Standard Precautions include a group of infection prevention practices that apply to all patients such as hand hygiene, use of gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure and safe injection practices. Contact precautions, droplet precautions, or airborne precautions may be added to standard precautions, if indicated."
Review of International Health Facility Guidelines (iHFG) on February 2, 2024, at 2 p.m. showed, "2.3 Handwash Basins [sinks] Handwash basins should be provided in rooms where procedures are likely to occur, including inpatient rooms, ICU bed bays, treatment and procedure rooms. ... 2 Hand Hygiene ... Handwash basins should be provided with the following: Paper towel dispenser and waste receptacle." Retrieved from https://www.healthfacilityguidelines.com/ViewPDF/ViewIndexPDF/iHFG_part_d_hand_hygiene
Observations at the Beaver Valley inpatient unit on February 1, 2024, at 9:30 a.m. were conducted in rooms 2, 3, 7, and 9. After observation of care in room 9 the registered nurse (RN) washed his/her hands using the room's sink. After RN finished washing his/her hands and while hands were dripping wet, he/she took some paper towels from a stack located directly on top of sink. As a result of no paper towel dispenser in room 9, unused paper towels in the stack were left wet from when RN washed his/her hands. Observation in the IPU's medication room revelaed it's sink also had no paper towel dispenser and only a stack of paper towels sitting directly on the counter.
Continued observations in the IPU's medication room and the patient isolation room 7 revealed agency had expired containers of disinfectant wipes that were available for use, "PDI Sani-Cloth Germicidal Disposable Wipe[s] [Expired] 9/2023."
Interview with EMP3 (clinical manager) and EMP4 (clinical supervisor) on February 2, 2024, at the time of observations and again at 10 a.m., confirmed findings and that none of the sinks at the Beaver Valley IPU have paper towel dispensers to protect them from contamination.
Review of "PDI Sani-Cloth" manufacturer's website on February 5, 2024, at 3:45 p.m. showed, "August 27, 2018 ... Please NOTE: Product can be used until the expiration date, even after being opened." Retrieved from https://pdihc.com/faq/where-can-i-find-the-expiration-date-on-sani-cloth-and-sani-prime-products-2/
Plan of Correction:How will the agency will correct the deficiency?
- The Agency will order and install towel dispensers in each patient room by the sinks.
- The Agency will remove all expired items from unit.
Measures or systems the Agency will alter to ensure the problem does not occur:
- Education will be provided on Policy 7.11 Infection Control plan as well as to routinely check supplies for expired items and discard if expired.
Plans to monitor the Agency's performance to ensure the problem does not occur:
- Weekly audits will be completed on the Beaver in-patient unit to ensure that each towel dispenser is in good working order and are being used by staff/families and that there are no expired supplies. Audits will be completed weekly for four weeks and then monthly for twelve months. Audits to be completed by Inpatient Unit supervisor or designee and will begin 3/4/2024.
Initial Comments:
Based on the findings of an onsite unannounced complaint investigation and state license survey completed February 5, 2024, Good Samaritan Hospice of Pittsburgh was found to be in compliance with the following requirement of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.
Plan of Correction:
Initial Comments:Based on the findings of an onsite unannounced complaint investigation and state license survey completed February 5, 2024, Good Samaritan Hospice of Pittsburgh was found to be in compliance with the requirement of 35 P.S. § 448.809 (b).
Plan of Correction:
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