QA Investigation Results

Pennsylvania Department of Health
COMPASSUS - ALLENTOWN
Health Inspection Results
COMPASSUS - ALLENTOWN
Health Inspection Results For:


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Initial Comments:


Based on the findings of an unannounced on-site hospice state re-licensure and licensure complaint survey completed on March 13, 2024, Compassus-Allentown 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 on-site hospice state re-licensure and licensure complaint survey completed on March 13, 2024, Compassus-Allentown was found not to be in compliance with the requirements of 42 CFR, Part 418, Subparts A, C &; D, Conditions of Participation: Hospice Care.











Plan of Correction:




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 on a review of agency policy/procedure, clinical record review, and an interview with the agency Administrator, it was determined that the agency failed to ensure volunteers were screened for TB (tuberculosis) upon hire, per policy, for two (2) of two (2) volunteer files(VF) reviewed (VF#5, VF#10).

Findings:

Agency policy/procedure was reviewed on March 11, 2024 at approximately 11:00 a.m. Policy 'C20, Volunteer Services' 'Policy Statement' includes " ..... Volunteers are treated the same as employed individuals regarding ....... health screenings ...... "
Procedure 'Tuberculosis (TB) Exposure Control Plan' 'Purpose' states "....All HCW providing patient care and volunteers are screened for TB at the time of hire and annually. ...... Effective 4/19/2021, Compassus adopts the latest CDC- recommended TB surveillance and detection methods to include use of IGRA blood testing in lieu of TB skin testing. ...... Compassus has partnered with a third party vendor to conduct HCW/volunteer testing and results will be retained in the HCW/volunteers personnel file ..."

A review of VFs was completed on March 11, 2024 at approximately 9:30 a.m.

VF#5, date of hire 09/28/23: No documentation provided of TB testing, per policy, at time of hire.

VF#10, date of hire 11/29/23: No documentation provided of TB testing, per policy, at time of hire.


An interview conducted with the agency Administrator on March 13, 2024, at approximately 11:30 a.m. and email correspondence with the agency Administrator on March 14, 2024 at approximately 12:15 p.m. confirmed the above findings.














Plan of Correction:

1. Business Office Coordinator to schedule identified volunteers for TST or IGRA blood test and upload results in Workday file.
2. An acknowledgement will be placed in identified volunteer files by Business Office Coordinator indicating that this deficiency was cited in a DOH survey conducted March 5-March 13, 2024 and the deficiency has been corrected.
3. ACO to provide re-training for Volunteer Coordinator, Business Office Coordinator and Directors of Clinical Services on Compassus Procedure C_11A- TB Exposure Control Plan.
4. BOC to review 100% of volunteer files for presence of initial TB results and correct any additional deficiencies identified.
5. BOC and VC will coordinate to ensure all new volunteers are scheduled for initial TB test within 7 days of hire as per Compassus policy.
6. Quarterly, the BOC will review 100% of new volunteer files to ensure presence of TB test results. If no TB test results are found, the volunteer will be removed from any active patient assignment until the TB test result are located or the TB test is re-done. This review will continue quarterly until 100% compliance is sustained for 4 quarters.
7. The results of monitoring will be reported to the QAPI committee quarterly for additional oversight.



418.100(c)(2) STANDARD
SERVICES

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(2) Nursing services, physician services, and drugs and biologicals (as specified in 418.106) must be made routinely available on a 24-hour basis 7 days a week. Other covered services must be available on a 24-hour basis when reasonable and necessary to meet the needs of the patient and family.


Observations:


Based on a review of agency policy/procedure, clinical record review, and an interview with the agency Administrator, it was determined that the agency failed to ensure the on-call registered nurse (RN) completed a home visit, per policy, for one (1) of one (1) complaint logs reviewed (Log Review #1).

Findings:

Agency policy/procedure was reviewed on March 11, 2024 at approximately 11:00 a.m. Agency ' Procedure: on Call Services ' ' Purpose ' " To ensure timely and appropriate intervention is provided by trained professional staff as needed by patients, families, and facility- based caregivers during non-business hours and to ensure compliance with 418.100 regarding availability of services on a 24-hour/day, 7-day week basis. " ' On-Call Requirements ' (1) " The on-call RN is available to respond to all calls received from the beginning to the end of the on-call shift. In the event an RN cannot be available due to a patient care need, the RN notifies the back-up nurse and/or the Administrator on call for support. " .... (3) " The on-call RN is the primary person responsible for communication regarding after hours responses and interventions required for positive patient care outcomes. .... " ... (4) ' Care Delivery (On My Way), ....(vi) If the patient or caregiver calls more than 1x in an after hours shift, a visit is made to provide in-person support, assessment, and reassurance. "

A review of the agency complaint log was completed on March 11, 2024 at approximately 11:00 a.m.

Log Review #1: Complaint received from (family member) of (CR#19) on 08/25/23 at 5:15 p.m. Section 'Describe the Occurrence/complaint: ".....No visit was made ........ Calls at 11:39 p.m., 12:36 a.m., and 1:45 a.m. ........"

The agency On-Call log was reviewed. Documentation provided of the three above listed calls. Documentation provided in 'Client Coordination Notes' of the On-Call nurse (Employee #6) providing instructions/interventions/education during each call.
Employee #6 did not conduct a home visit after receiving more than one call in the after hours shift, per policy.

An interview conducted with the agency Administrator on March 13, 2024, at approximately 11:30 a.m. and email correspondence with the agency Administrator on March 14, 2024 at approximately 12:15 p.m. confirmed the above findings.














Plan of Correction:

1. Compassus to follow-up with complainant via phone and/or letter. Documentation of correspondence will be retained with the complaint file.
2. DCS or designee to provide training to nurses on Compassus Procedure C_22A On Call Services, including expectations of response time, visits and documentation of interventions provided.
3. Review of 100% on-call log entries weekly by DCS until 100% compliance with On Call Services Procedure is achieved for 4 consecutive weeks.
4. Once compliance is achieved, DCS will continue to review 3 on call log entries monthly to monitor for compliance and provide 1:1 remedial training to nurses as needed.
5. The results of monitoring will be reported to the QAPI committee monthly for additional oversight.



418.104(e)(2) STANDARD
DISCHARGE OR TRANSFER OF CARE

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(2) If a patient revokes the election of hospice care, or is discharged from hospice in accordance with 418.26, the hospice must forward to the patient's attending physician, a copy of-
(i) The hospice discharge summary; and
(ii) The patient's clinical record, if requested.



Observations:


Based on a review of agency policy/procedure, clinical record review, and an interview with the agency Administrator, it was determined that the agency discharged patients without patient revocation or without cause for two (2) of two (2) discharged clinical records (CR) reviewed (CR #16, CR#17).

Findings:

'Discharge from hospice care.' " (a) Reasons for discharge. A hospice may discharge a patient if - (1) The patient moves out of the hospice's service area or transfers to another hospice; (2) The hospice determines that the patient is no longer terminally ill; or, (3) The hospice determines, under a policy set by the hospice for the purpose of addressing discharge for cause that meets the requirements of ....."

Agency policy/procedure was reviewed on March 11, 2024 at approximately 11:00 a.m. 'Procedure' Discharge/Transfer/Revocation Not related to missed Face to Face Evaluation' 'Purpose' "To provide guidance and direction for the appropriate steps for live discharge to ensure state and federal regulatory compliance....." 'Procedure' (1) Discharge (a) A hospice may discharge a patient from services in only a few specific circumstances: (i) The patient is deceased. (ii) The patient is no longer eligible due to a prognosis of greater than 6 months (iii) The patient has moved out of the hospices service area. (1) If the patient enters a hospital or nursing facility with which the hospice is unable to obtain a contract and the patient is not accessible to the hospice, this is considered a discharge out of the service area. The hospice is expected to thoroughly investigate and make a determination about the patients hospice care needs and whether the non-contracted facility is providing unrelated services and/or whether the non-contracted facility is willing to negotiate a one-time contract to permit the hospice access to the patient." (Note: This policy is not compliant with regulation.)

A review of CRs was completed on March 11, 2024 at approximately 11:00 a.m.

CR#16, start of care 09/12/23, discharged 09/30/23: 'Client Coordination Note Report' dated 10/02/23 'Note' "Call to regional hospital. Patient admitted 9/30 ..... Discharge from hospice services -Out of Service Area non-contracted facility."
Documentation provided of 'Termination of Hospice Benefits' signed by the Medical Director and the hospice representative on 10/12/23. The section 'Other Discharge' includes 'Medical Director Order: Discharge from hospices services.' 'Moved out of Service Area' 'Effective Date: 09/30/23'.
No documentation provided of the patient revoking hospice or of being discharged for cause that meets the requirements of the regulation.

CR#17, start of care 09/21/23, discharged 10/25/23: 'Order Date' dated 10/25/23 'Order Type' 'Hospice Discharge' 'Order Description' "Patient admitted to regional hospital-Non-contracted facility on 10/25/23."
Documentation provided of 'Termination of Hospice Benefits' signed by the Medical Director and the hospice representative on 10/25/23. The section 'Other Discharge' includes 'Medical Director Order: Discharge from hospices services.' 'Moved out of Service Area' 'Effective Date: 10/25/23'.
No documentation provided of the patient revoking hospice or of being discharged for cause that meets the requirements of the regulation.


An interview conducted with the agency Administrator on March 13, 2024, at approximately 11:30 a.m. and email correspondence with the agency Administrator on March 14, 2024 at approximately 12:15 p.m. confirmed the above findings.
















Plan of Correction:

1. For the patient record CR#16, the nurse who failed to visit the patient and secure appropriate discharge documentation indicating the patient's choice to revoke the hospice benefit due to hospitalization for an issue related to the terminal illness was terminated from employment on 4.19.2024.
2. For the patient record CR#17, the patient was sent to a non-contracted hospital due to the patient's critical status. In this situation, a discharge for cause could have been completed but the additional information regarding the unrelated nature of the patient's reason for hospitalization also supports a discharge out of the service area. No additional documentation is available. The nurse case manager who did not provide complete documentation of the discussion regarding discharge options received education from the Director of Quality Outcomes.
3. The agency's policy and procedure were updated to reflect specific direction regarding the circumstances and actions related to communicating with patients and/ or their representative regarding options for self-determination related to hospice services including revocation, transfer, or discharge for an acceptably defined reason.
4. All hospice clinical team members were provided education on the revisions to the policy and procedure with emphasis on the patient's options and the agency's obligation to provide information and support for decision-making.
5. Live discharges for the prior 30 days will be reviewed to ensure there is appropriate documentation of the reason the patient was discharged, revoked, or was transferred and that the patient/ representative signed a revocation or transfer form where appropriate records that are missing these documents cannot be amended due to the loss of time.
6. Any patient discharges will be done according to CFR 418.26.
7. Beginning 5/20/2024, the DCS or designee will review 100% of live discharges each week to verify all required documentation including the correct reason for the discharge is included in the medical record. This review will continue weekly until 100% compliance is sustained for 4 consecutive weeks.
8. When this threshold is achieved, reviews will be reduced to 20% of live discharges monthly to ensure documentation is sustained at 100% compliance for an additional 3 months.
9. The results of all reviews and any re-education will be reported to the QAPI committee monthly for additional direction and oversight.





418.112(f) STANDARD
ORIENTATION AND TRAINING OF STAFF

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Hospice staff, in coordination with SNF/NF or ICF/IID facility staff, must assure orientation of such staff furnishing care to hospice patients in the hospice philosophy, including hospice policies and procedures regarding methods of comfort, pain control, symptom management, as well as principles about death and dying, individual responses to death, patient rights, appropriate forms, and record keeping requirements.

Observations:


Based on a request/review of agency policy/procedure, a review of hospice services contracts, and an interview with the agency Administrator, agency failed to assure hospice philosophy orientation for skilled nursing facility staff for two (2) of three (3) skilled nursing facility contracts (SNFC) reviewed (SNFC#2, SNFC#3).

Findings include:

Agency policy/procedure was reviewed on March 11, 2024 at approximately 11:00 a.m. 'Procedure' 'Managing Contracted Entities' "Procedure' section (4) "Establishing training and evaluation procedures for contracted individuals, vendors, and facility staff : ......(b) Contracted vendors and facilities are provided with training materials to provide to their staff who may be assigned to a Compassus patient. These materials are incorporated by the contracted vendor or facility into their standard orientation and/or annual education practices. A copy of provided materials is retained in the contract file by the Compassus hospice location. ......."

Facility contracts were reviewed on March 10, 2024 at approximately 1:00 p.m.

SNFC#2: Documentation provided of 'Nursing Facility Hospice, General Inpatient and Respite Care Services Agreement'' signed by the hospice agency (referred to as 'Hospice') on 11/03/22 and the skilled nursing facility (SNF#1, referred to as 'Facility') signed on 11/03/22. 'Part II, Services to be provided by Hospice: (A) Nursing Facility Hospice Services: section (6) "Hospice will retain responsibility for appropriate hospice care training of facility staff furnishing care to hospice patients and will assure orientation of such staff in the hospice philosophy, including the hospice policies and procedures, ..... "

Documentation provided of a 'Facility/Vendor Staff Education' form being signed by a facility representative ("Admissions") on 11/13/23. A hospice designee also signed the form on 11/13/23. The first section of the form includes "I have received the following policies and have had the opportunity to have my questions answered. (Check policies and modules that apply.) 'Compassus Hospice Policy with two sections, 'Patients Rights' and 'Non-discrimination Policy and Grievance process' were checked off.
The second section of the form includes "I have received the following education module/s and will/have provided to all appropriate employees for the year 2023. 'Compassus Hospice Education Module' with 'Introduction to Hospice (SNF/ALF only) checked off.
(Hospice patient Clinical Record #1, start of care 01/31/24, currently resides/resided at this facility.)

No documentation provided of the hospice agency assuring the orientation of the skilled nursing facility staff who furnish care to hospice patients to the hospice philosophy.

SNFC#3: Documentation provided of 'Provider Agreement' signed by the hospice agency (referred to as 'Agency') on 05/11/21 and the skilled nursing facility (SNF#1, referred to as 'Facility') signed on 05/11/21. Section (d), 'Services to be provided by Agency', (vi) Agency retains responsibility for ensuring that the training of personnel who will be providing the Agency Hospice Patients care in the facility has been provided and that a description of the training and the names of those giving the training are documented.

Documentation provided of a 'Facility/Vendor Staff Education' form being signed by a facility representative ("Administrator") on 12/11/23. A hospice designee also signed the form on 12/11/23. The first section of the form includes "I have received the following policies and have had the opportunity to have my questions answered. (Check policies and modules that apply.) 'Compassus Hospice Policy with two sections, 'Patients Rights' and 'Non-discrimination Policy and Grievance process' were checked off.
The second section of the form includes "I have received the following education module/s and will/have provided to all appropriate employees for the year 2023. 'Compassus Hospice Education Module' with 'Introduction to Hospice (SNF/ALF only) and Pain Management (SNF/ALF only) were checked off.
(Hospice patient Clinical Record #4, start of care 10/27/23, currently resides/resided at this facility.)

No documentation provided of the hospice agency assuring the orientation of the skilled nursing facility staff who furnish care to hospice patients to the hospice philosophy.


An interview conducted with the agency Administrator on March 13, 2024, at approximately 11:30 a.m. and email correspondence with the agency Administrator on March 14, 2024 at approximately 12:15 p.m. confirmed the above findings.












Plan of Correction:

1. On-site education regarding care provision to hospice patients and the hospice benefit to be provided by the hospice to the facilities identified in survey, with evidence of participation by individuals at the facility to be collected when the training is provided.
   2. ACO/DQO to provide training to hospice team members on Procedure C_25A Managing Contracted Entities. This will include the opportunity for the clinical team to conduct training with individual members of the facility staff during the provision of patient care with the capture of the individual's name who receive such training in the clinical note.
3. Hospice will provide hospice-specific training to facility staff at least annually. Hospice will obtain attendance records for trainings conducted by the hospice for contract files.
4. The DCS or designee will report update on completion of each contracted facility's annual staff training and identify needs for additional training during QAPI meeting in the quarter when the contract review occurs



Initial Comments:


Based on the findings of an unannounced on-site hospice state re-licensure and licensure complaint survey completed on March 13, 2024, Compassus-Allentown 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 on-site hospice state re-licensure and licensure complaint survey completed on March 13, 2024, Compassus-Allentown was found to be in compliance with the requirements of 35 P.S. 448.809 (b).








Plan of Correction: