Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification and State relicensure survey completed on 10/22/2021, AseraCare 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 onsite unannounced Medicare recertification and state relicensure survey completed 10/22/2021, AseraCare Hospice 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:
418.54(c)(6) STANDARD
CONTENT OF COMPREHENSIVE ASSESSMENT
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[The comprehensive assessment must take into consideration the following factors:]
(6) Drug profile. A review of all of the patient's prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy. This includes, but is not limited to, identification of the following:
(i) Effectiveness of drug therapy
(ii) Drug side effects
(iii) Actual or potential drug interactions
(iv) Duplicate drug therapy
(v) Drug therapy currently associated with laboratory monitoring.
Observations:
Based on review of agency policy, medical records (MR), observation, and staff (EMP) interviews, the agency failed to review all the patient's medications and update the medication profile and allergies for one (1) of thirteen (13) MR reviewed (MR7).
Findings included:
A review of agency policy and procedure on 10/21/2021 at approximately 3:25 PM revealed, Policy "Medication Management ...Policy: The Hospice provides safe medication management through implementation of guidelines and Clinical Policies that address communication, medications administration, disposal, documentation and education of patients and staff ...E. Medication Reconciliation: 1. Medication Reconciliation will be done at admission, recertification, a change in patient ' s condition requiring medication changes, when a medication is discontinued, when a new order, or change in existing medication order. Nurse to review patient ' s allergies during medication reconciliation ... "
A review of MR7 on 10/21/2021 at approximately 11:15 AM revealed, A "Client Medication Report" with the start of care date of 10/9/2019 for a current certification period starting 9/28/2021 and ending 11/26/2021. The primary diagnosis was atherosclerotic heart disease of the native coronary artery without angina pectoris. The allergies listed on the client medication report was " MORPHINE. " An order was documented on the client medication report for " MORPHINE CONCENTRATE 100MG/5ML (20 MG/ML) ORAL SOLUTION ...(start date) 1/14/2020 ...Instructions: EVERY HOUR PRN FOR PAIN OR SOB ... " No documentation from 1/14/2020 to current was provided to confirm the order was addressed related to the listed allergy.
An exit interview was conducted in person on 10/21/2021 at approximately 3:30 PM with the administrator, clinical supervisor, branch administrator, regional vice president, area vice president of operations and (via phone) clinical vice president which confirmed the above findings.
Plan of Correction:L523:418.54(c ) Content of Comprehensive Assessment
1. On 10/22/21 – 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 Operations implemented comprehensive and systematic changes to ensure ALL clinical staff members reviewed Medication Management Policy that states Hospice will provide safe medication management through implementation of guidelines and Clinical Policies that address communication, medications administration, disposal, documentation and education of patients and staff. Medication Reconciliation will be done at admission, recertification, a change in patient's condition requiring medication changes, when a medication is discontinued, and when there is a new order, or change in existing medication order. Nurse to review patient ' s allergies during medication reconciliation.
2. On 10/22/21, the Administrator/Director of Operations, the Area Vice President of Operations and the Area Vice President of Clinical Operations provided:
- Education/Training - Initiated 10/22/21 Comprehensive re-education and remediation for ALL staff was on appropriate agency policies related to deficient areas:
- Review of Agency Policies and Procedures:
o MM-001A Medication Management Policy
o AA-005 Hospice plan of care.
o AA-003 Assessments
3 Ongoing education/training and monitoring was implemented as follows: The Administrator/Director of Operations and Clinical Manger initiated the following to ensure ongoing compliance:
- All new admissions will be audited weekly until 100% compliance that patient allergies were reconciled with current medication profile until 100% threshold has been maintained x 1 month then 2021 and then 10% of all admissions audited monthly until 100% compliance has been maintained for two consecutive quarters. 100% of all current patient allergies and medication reconciliation will be completed within the next 30 days.
- 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.
- Completion Date: 12/20/2021
418.60(a) STANDARD
PREVENTION
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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 on review of agency policy and procedure, observation during home visits (OBV), and staff (EMP) interviews, the agency failed to ensure one (1) of four (4) employees followed infection control policy and procedure for bag technique (EMP10).
Findings included:
A review of MR7 on 10/21/2021 at approximately 11:15 AM revealed, Policy " Bag Technique ...PURPOSE: To provide guidelines for the adherence of the principles of infection prevention in relationship to practitioner equipment and supply bag usage ...GUIDELINES ...Supply bags are cleaned when visible soiled and at least monthly. Surface barrier materials should be a water-resistant material, should protect the full bottom surface of the supply bag, used on a one-time basis and discarded as household waste. PROCEDURE: 1. Bags are placed on a barrier in the patient ' s home. Bags should not be placed on padded furniture, such as sofas or beds without a barrier. Bags should not be placed on the floor in the patient ' s home. The bag may be hung on a doorknob or the back of a heavy chair ... "
Observations during a visit to patient ' s residence (MR13) on 10/20/2021 at approximately 10:52 AM which revealed: EMP10 provided direct patient care. EMP10 placed a white paper chuck/barrier on a metal folding chair. Then nursing bag extended an estimate two inches beyond the chuck/barrier on one side. The strap of the nursing bag laid to one side of the nursing bag and rested on the back of the metal chair. Upon exit from the residence the bottom of the bag and strap was not cleaned/disinfected. After exit from the patient ' s residence the surveyor notified EMP10 that parts of the bag were not protected by the chuck/barrier.
An exit interview was conducted in person on 10/21/2021 at approximately 3:30 PM with the administrator, clinical supervisor, branch administrator, regional vice president, area vice president of operations and (via phone) clinical vice president which confirmed the above findings.
Plan of Correction:L579:418.60 INFECTION CONTROL: (a) Prevention
1. On 10/22/21 - 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 Operations implemented comprehensive and systematic changes to ensure ALL staff members completed a remediation of bag technique and infection prevention program to ensure proper technique. The Director of Operations, Assistant Vice President of Operations and Assistant Vice President of Clinical Operations implemented measures to ensure identified deficiencies would not reoccur as evidenced by education and training.
2. On 10/22/21, the Administrator/Director of Operations, the Area Vice President of Operations and the Area Vice President of Clinical Operations provided:
- Education/Training - Initiated 10/22/21 Comprehensive re-education and remediation for ALL staff was on appropriate agency policies related to deficient areas:
- Review of Agency Policies and Procedures:
o PCP-002 Bag Technique
o PCP-003 Equipment Decontamination
o PCP-001 Hand hygiene
- Identification/Implementation – Initiated on 10/22/21, The Director of Operation/Clinical Mangers held a mandatory Teams meeting to review proper bag technique and decontamination of equipment between visits.
3. Ongoing education/training and monitoring was implemented as follows: The Administrator/Director of Operations and designees initiated the following to ensure ongoing compliance:
- 5 staff members will be observed monthly until all staff have been observed with bag technique and decontamination and hand washing. Ongoing, 10% of the auditing of current patient plan of care and infection control follow up will continue quarterly moving thereafter with staff remediation including reeducation as needed when problems are identified.
- 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.
- Completion Date: 12/20/2021
Initial Comments:
Based on the findings of an onsite unannounced State relicensure survey completed 10/22/2021, AseraCare Hospice was found to be in compliance with the requirements 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 State relicensure survey completed 10/22/2021, AseraCare Hospice was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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