Initial Comments:Based on the findings of an unannounced on-site state re-licensure and federal recertification survey completed on October 25, 2024, Aseracare Hospice was found not 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 state re-licensure and federal recertification survey completed on October 25, 2024, Aseracare Hospice 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
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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 a review of agency policy/procedure, a review of employee files, and an interview with the agency Administrator, it was determined that the agency failed to ensure tuberculosis (TB) screening was conducted, per policy, for two (2) of seven (7) employee files (EF) reviewed (EF#4, EF#5).
Agency policy/procedure reviewed on October 25, 2024 at approximately 11:30 p.m. Policy 'Tuberculosis Screening and Testing' 'Purpose' "To properly screen all direct patient care staff for the presence of TB at the time of employment." 'Procedure' (1) Baseline screening and testing of newly hired staff' .... (b) "Newly hired staff without a documented negative TB test in the past (12) months will .... and get tested with a 2-step TB skin test or a single TB blood test."
A review of EFs was conducted on October 22, 2024 at approximately 10:45 a.m. The employees date of hire (DOH) is included below.
EF#4, DOH 04/24/23: No documentation of the agency conducting a two-step TB test or TB blood test. A single step TST (tuberculin skin test) was administered on 05/03/23.
EF#5, DOH 11/14/22: No documentation of the agency conducting a two-step TB test or TB blood test. A single step TST (tuberculin skin test) was administered on 11/01/22.
An interview conducted with the agency Administrator on October 25, 2024 at approximately 11:45 p.m. confirmed the above findings.
Plan of Correction:TAG L0579- 418.60(a) Prevention: Tuberculosis Screening:
1. Corrective Action / Preventing Reoccurrence: On 10/25/2024, upon notification of areas of deficiencies, the Administrator/Director of Operations, with the assistance of the Area Vice President of Clinical Operations, reviewed that tuberculosis screening shall be completed on all direct care staff to assess for presence of TB at the time of employment. All staff without a documented negative TB test within the past 12 months of the date of hire will require a 2-step TB test, a single TB blood test or a Tuberculosis Risk Assessment/ Screening Questionnaire with a negative chest x-ray or physician statement.
- Education/Training: On 11/05/2024, the Administrator/Director of Operations and Area Vice President of Clinical Operations provided Comprehensive re-education and remediation for all staff on appropriate agency policies related to deficient areas:
- Review of all Agency Policies and Procedures
o CR-TBP-003 Tuberculosis Screening and Testing
o HR-001A Personnel File Requirements for Care Center Staff
- Implementation & Monitoring:
o The Administrator/Director of Operations, Business Office Manager and Clinical manager will ensure compliance assuring that the staff have proper onboarding with prevention screening and testing, including tuberculosis screening in accordance with state and federal guidelines.
- All personnel files will be audited starting the week of 11/05/2024 to assure proper screening and tuberculosis testing has been completed. The Clinical Manager/ Business Office Manager/ Administrator Director of Operations will audit all personnel charts, including volunteer staff, to ensure that all have had completed tuberculosis testing and screening. Any staff member missing proper testing/screening as per guidelines, will be screened and/or tested within 30 days. Once all personnel files reach 100% compliance, Business Office Manager will review 3 employee records monthly to assure 100% compliance is maintained for 6 months.
- 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: 12/9/2024
418.78(e) STANDARD
LEVEL OF ACTIVITY
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Volunteers must provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract staff. The hospice must maintain records on the use of volunteers for patient care and administrative services, including the type of services and time worked.
Observations:
Based on a review of agency policy/procedure, a review of the agency volunteer utilization records, and an interview with the agency Administrator, the agency failed to ensure volunteers provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours, for one (1) of one (1) volunteer cost savings documentation (VCSD) reviewed (VD#1).
Agency policy/procedure reviewed on October 25, 2024 at approximately 11:30 p.m. 'Volunteers' 'Operational Guidelines' "..... The hospice will document and maintain a volunteer staff sufficient to provide direct patient care in an amount that, at a minimum, equals five (5) percent of the total patient care hours of all paid hospice personnel."
VCSD was reviewed on October 22, 2024 at approximately 1:00 p.m.
VD#1: Volunteer cost savings was requested for the past (12) months. Documentation provided of September 2023 - September 2024 (13 months). Per the agency Administrator, the average volunteer hours percentage was 1.4%. No other documentation provided.
The total cost savings equated to less then five (5) percent of the total patient care hours.
An interview conducted with the agency Administrator on October 25, 2024 at approximately 11:45 p.m. confirmed the above findings.
Plan of Correction:TAG L0647-418.78(3) Level of Activity: Volunteer:
2. Corrective Action / Preventing Reoccurrence: On 10/25/2024, upon notification of areas of deficiencies, the Administrator/Director of Operations, with the assistance of the Area Vice President of Clinical Operations, reviewed that volunteers should provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5% of the total patient care hours.
- Education/Training: On 11/05/2024, the Administrator/Director of Operations with assistance of the Area Vice President of Clinical Operations provided Comprehensive re-education and remediation for all staff on appropriate agency policies related to deficient areas:
- Review of all Agency Policies and Procedures
o TX-017A- Volunteers
- Education to all staff regarding utilization of volunteers and discussion of volunteer services for current and future patients.
- Implementation & Monitoring:
o The Administrator/Director of Operations, Clinical Manager and Regional Volunteer Coordinator will ensure ongoing education and coordination to meet and maintain the 5% volunteer services threshold.
- Regional Volunteer Coordinator, Director of Operations and Clinical Manager to hold weekly virtual meetings to discuss current volunteer utilization and opportunities, as well as retention, onboarding and recruiting events for volunteers. This meeting will continue on a weekly basis until 5% threshold has been met and sustained for 3 months.
- Once threshold is met for 3 months, meetings to continue monthly to assure ongoing oversight and compliance for 3 additional months.
- 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: 12/9/2024
418.104(e)(1) STANDARD
DISCHARGE OR TRANSFER OF CARE
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(1) If the care of a patient is transferred to another Medicare/Medicaid-certified facility, the hospice must forward, to the receiving facility, 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 failed to send the patients discharge summary to the receiving hospice agency for one (1) of one (1) clinical record (CR) patient transfer reviews (CR#18).
Agency policy/procedure reviewed on October 25, 2024 at approximately 11:30 p.m. 'Discharge' 'Operational Guidelines' ".... (f) "When the patient is discharged to another organization, relevant medical information is provided to that agency and/or patient, when requested, including: .... (c) "Summary of Care provided by the hospice agency."
A review of CRs was completed on October 25, 2024 at approximately 11:30 a.m.
CR#18 Start of Care 05/07/24: Patient transfer date to another Hospice was 06/14/24. No documentation provided of the discharge summary being sent to the receiving hospice agency.
An interview conducted with the agency Administrator on October 25, 2024 at approximately 11:45 p.m. confirmed the above findings.
Repeat deficiency.
Plan of Correction:TAG L0682-418.104(e) Discharge or Transfer of Care, Transfers:
3. Corrective Action / Preventing Reoccurrence: On 10/25/2024, upon notification of areas of deficiencies, the Administrator/Director of Operations, with the assistance of the Area Vice President of Clinical Operations, reviewed that all patients transferred to another Medicare/Medicaid-certified facility shall receive a copy of the hospice discharge/transfer summary and if requested, the patient's clinical record.
- Education/Training: On 11/05/2024, the Administrator/Director of Operations with assistance of the Area Vice President of Clinical Operations provided Comprehensive re-education and remediation for all staff on appropriate agency policies related to deficient areas:
- Review of all Agency Policies and Procedures
o AA-012 Transfer of Patients
o AA-013A Discharge
- Education to all staff regarding proper procedure with discharge regarding proper report off as well as sending necessary paperwork, including a copy of the discharge/transfer summary and if requested, the patient's clinical record.
- Implementation & Monitoring:
o The Administrator/Director of Operations and Clinical Manager will audit all discharges and transfers for 2 months, until 100% compliance is achieved. Once 100% compliance is achieved, the administrator/Director of Operations and Clinical Manager will review 3 live discharges/transfers to assure compliance is maintained.
- 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: 12/9/2024
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 failed to send the patients discharge summary to the attending physician for one (1) of one (1) clinical record (CR) patient transfer reviews (CR#19).
Agency policy/procedure reviewed on October 25, 2024 at approximately 11:30 p.m. 'Discharge' 'Operational Guidelines' ".... (C) "The Discharge process is as follows: ..... (j) If a patient is discharged alive, the hospice will forward to the attending physician: (i) "A copy of the hospice discharge summary."
A review of CRs was completed on October 25, 2024 at approximately 11:30 a.m.
CR#19 Start of Care 01/03/24: Patient hospice revocation was 01/09/24. No documentation provided of the discharge summary being sent to the patients attending physician.
An interview conducted with the agency Administrator on October 25, 2024 at approximately 11:45 p.m. confirmed the above findings.
Plan of Correction:TAG L0683-418.104(e)(2) Discharge or Transfer of Care: Revocations
4. Corrective Action / Preventing Reoccurrence: On 10/25/2024, upon notification of areas of deficiencies, the Administrator/Director of Operations, with the assistance of the Area Vice President of Clinical Operations, reviewed that all patients that revoke the election of hospice care, or is discharged from hospice, shall receive a copy of the hospice discharge/transfer summary and if requested, the patient's clinical record, and it will be provided to the attending physician and/or receiving facility.
- Education/Training: On 11/05/2024, the Administrator/Director of Operations with assistance of the Area Vice President of Clinical Operations provided Comprehensive re-education and remediation for all staff on appropriate agency policies related to deficient areas:
- Review of all Agency Policies and Procedures
o AA-014 Revocation
o AA-013A Discharge
- Education to all staff regarding proper procedure with discharge including transfers, revocations and live discharges regarding proper report off as well as sending necessary paperwork, including a copy of the discharge/transfer summary and if requested, the patient's clinical record.
- Implementation & Monitoring:
o The Administrator/Director of Operations and Clinical Manager will audit all discharges, including revocations for 2 months, until 100% compliance is achieved. Once 100% compliance is achieved, the administrator/Director of Operations and Clinical Manager will review 3 discharged charts monthly to assure compliance is maintained.
- 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: 12/9/2024
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 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 three (3) of three (3) skilled nursing facility contracts (SNFC) reviewed (SNFC#1 - SNFC#3).
Agency policy/procedure reviewed on October 25, 2024 at approximately 11:30 p.m. Policy 'HR-01D' 'Orientation-Contract Personnel' 'Operational Guidelines' (6) "Orientation will be provided to contracted nursing facility staff will include: (a) hospice policies and procedures regarding pain and symptom management. (b) Principles of death and dying. (c) Individual response to death. (d) Patient rights. (e) Appropriate forms. (f) Record keeping requirements."
SNFC were reviewed on October 24, 2024 at approximately 2:00 p.m.
SNFC #1: Documentation provided of a 'Professional Service Contract', 'Beginning Date: November 1, 2023, Termination Date: October 31, 2027", signed by the skilled nurse facility (county) and the hospice agency. Section E. 'Orientation and training of staff' (i) (Hospice) will assure orientation of (facility) staff furnishing care to hospice residents in the hospice philosophy, ...."
Documentation provided of the most recent hospice patient (clinical record #21) residing at this facility 06/02/24. There are currently (0) hospice patients residing at this facility.
Documentation requested of the agency assuring hospice philosophy orientation for skilled nursing facility staff was requested on October 24, 2024 at approximately 2:30 p.m. No documentation provided. Documentation provided of a 'Sign in Sheet' with 'Topic' "(Facility name listed in this section and not actual topic of inservice), Location: (blank with no entry), Instructor: (blank with no entry), Date: (blank with no entry), participant section included eight (8) names.
SNFC #2: Documentation provided of a 'Hospice Care Services Agreement', beginning date January 3, 2019 with an automatic renew unless earlier terminated, signed by the skilled nurse facility and the hospice agency. 'Comparison of Facility/Hospice Responsibilities' lists the hospice agency as being responsible for 'Orientation and training of facility staff to include: Hospice philosophy, ..."
Documentation provided of two (2) hospice patients (clinical record # 22, #23) currently residing at this facility.
Documentation requested of the agency assuring hospice philosophy orientation for skilled nursing facility staff was requested on October 24, 2024 at approximately 2:30 p.m. No documentation provided.
SNFC #3: Documentation provided of a 'Nursing Facility Services Agreement' effective June 24, 2024, signed by the skilled nurse facility and the hospice agency. Section (iv) 'Hospice Training' "..... For personnel who have not received hospice training, Hospice shall provide training and shall document the names of the individuals who gave the training and a description of the training. ...."
Documentation provided of one (1) hospice patient (clinical record #24) currently residing at this facility.
Documentation requested of the agency assuring hospice philosophy orientation for skilled nursing facility staff was requested on October 24, 2024 at approximately 2:30 p.m. No documentation provided.
An interview conducted with the agency Administrator on October 25, 2024 at approximately 11:45 p.m. confirmed the above findings.
Repeat deficiency.
Plan of Correction:TAG L0782-418.112(f) Orientation and Training of Staff: Facility education:
5. Corrective Action / Preventing Reoccurrence: On 10/25/2024, upon notification of areas of deficiencies, the Administrator/Director of Operations, with the assistance of the Area Vice President of Clinical Operations, reviewed that all 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.
- Education/Training: On 11/05/2024, the Administrator/Director of Operations with assistance of the Area Vice President of Clinical Operations provided Comprehensive re-education and remediation for all staff on appropriate agency policies related to deficient areas:
- Review of all Agency Policies and Procedures
o TX-005 Professional Management
o HR-01D Orientation- Contract Personnel
- Education to all staff regarding education to facilities and contracted facilities to assure accurate and timely in-service provided from hospice team.
- Implementation & Monitoring:
o The Administrator/Director of Operations, Clinical Manager and Business Office Manager will ensure ongoing education and coordination to assure that all contracted facilities have received necessary education within the time requirements.
- The Administrator/Director of Operations with assistance from the clinical manager and business office manager, will complete a comprehensive review of 100% of all contracted facilities to assure that education has been provided within the last 1 year.
i. All facilities will schedule a hospice in-service with the hospice team within the next 60 days to be completed.
- The Administrator/Director of Operations will review weekly with the team to assure 100% compliance is reviewed.
- Once 100% compliance is achieved, the administrator will review 10% of contracted facilities on a quarterly basis to assure compliance is maintained.
- 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: 12/9/2024
418.114(d)(2) STANDARD
CRIMINAL BACKGROUND CHECKS
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Criminal background checks must be obtained in accordance with State requirements. In the absence of State requirements, criminal background checks must be obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years.
Observations:
Based on a review of agency policy/procedure, a review of employee files, and an interview with the agency Administrator, it was determined that the agency failed to ensure a federal criminal history record was conducted, per policy, for one (1) of seven (7) employee files (EF) reviewed (EF#4).
Agency policy/procedure reviewed on October 25, 2024 at approximately 11:30 p.m. Policy 'HR-007' 'Criminal and Motor Vehicle Background Checks and Conviction that Bar and Employees application/Employment' 'Pennsylvania' (a) (2) "Federal criminal history record. If the applicant is not and for the 2 years immediately preceding the date of application has not been a resident of this Commonwealth, the facility shall require the applicant to submit a Federal criminal history record and a full set of fingerprints to the Department which will forwarded to the Federal Bureau of Investigation."
A review of EFs was conducted on October 22, 2024 at approximately 10:45 a.m. The employees date of hire (DOH) is included below.
EF#4, DOH 04/24/23: No documentation of the agency conducting a federal criminal history record check per policy. Per the agency Business Office Manager (employee #10) on 10/24/24 at approximately 2:30 p.m, employee #10 was informed by the employee that employee relocated to Pennsylvanian the day before he started working for the agency. Documentation provided of employee #4 having a State of Delaware driving license.
An interview conducted with the agency Administrator on October 25, 2024 at approximately 11:45 p.m. confirmed the above findings.
Repeat deficiency.
Plan of Correction:TAG L0796-418.114(d)(2) Background Checks:
6. Corrective Action / Preventing Reoccurrence: On 10/25/2024, upon notification of areas of deficiencies, the Administrator/Director of Operations, with the assistance of the Area Vice President of Clinical Operations, reviewed that all new employees must have background checks obtained in accordance with State requirements. In the absence of state requirements, criminal background checks must be obtained within three months of the date of employment for all states that the individual has lived or worked in in the past 3 years.
- Education/Training: On 11/05/2024, the Administrator/Director of Operations with assistance of the Area Vice President of Clinical Operations provided Comprehensive re-education and remediation for all staff on appropriate agency policies related to deficient areas:
- Review of all Agency Policies and Procedures
o HR-001 Personnel Files
o HR-007 Criminal and Motor Vehicle Background Checks.
- Education to staff regarding proper procedure for obtaining background and motor vehicle checks for all employees.
- Implementation & Monitoring:
o The Administrator/Director of Operations, Clinical Manager and Business Office Manager will ensure ongoing education and coordination to reach and maintain 100% compliance.
o The Business office Manager will complete 100% audit of all personnel files for employees. We will continue this audit until 100% compliance is achieved.
o To assure continued compliance, the Business Office Manager will review 3 personnel files monthly to assure maintenance at 100% compliance.
o Once 100% compliance is achieved for 3 months, the business office manager will then review 3 personnel files quarterly.
- 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: 12/9/2024
Initial Comments:Based on the findings of an unannounced on-site state re-licensure survey completed on October 25, 2024, Aseracare 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 on-site state re-licensure survey completed on October 25, 2024, 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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