QA Investigation Results

Pennsylvania Department of Health
CARING HOSPICE SERVICES
Health Inspection Results
CARING HOSPICE SERVICES
Health Inspection Results For:


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Initial Comments:Based on the findings of an onsite unannounced state relicensure and Medicare recertification survey completed 4/25/2024, Caring Hospice Services - Monroeville 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 state relicensure and Medicare recertification survey completed 4/25/2024, Caring Hospice Services - Monroeville was found not to be in compliance with the requirements of 42 CFR, Part 418, Subparts A, C, and D, Conditions of Participation: Hospice Care.




Plan of Correction:




418.76(g)(1) STANDARD
HOSPICE AIDE ASSIGNMENTS AND DUTIES

Name - Component - 00
(1) Hospice aides are assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group. Written patient care instructions for a hospice aide must be prepared by a registered nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of this section.


Observations: Based on review of agency policy and clinical records (CR) and staff (EMP) interview, the agency failed to ensure the needs of the patients were met for two (2) of twelve (12) CR's reviewed (CR9 and CR11). Findings include: A review of the agency policy "Clinical Record Guidelines for Electronic Medical Records" revealed "Notes must be completed, reviewed and synchronized to the clinical record as soon as possible after the visit. This will occur within 48 hours of the visit, but no less often than weekly." A review of CR9 on 4/24/24, at 11:59 a.m. revealed Start of Service date was 12/11/23, and certification review period from 3/10/24 to 6/7/24, revealed physician ordered frequencies of Home Health Aides visits from 3/10/24 to 6/7/24 was 5 times a week. A review of his Home Health Aides (HHA) notes for the weeks starting 3/17/24, 3/24/24, 3/31/24, 4/7/24 and 4/14/24, revealed no documented evidence that an HHA provided care to CR9. A review of CR11 on 4/24/24, at 2:00 p.m. revealed Start of Service date was 4/2/24, and certification review period from 4/2/24 to 6/30/24, revealed physician ordered frequencies of Home Health Aide visits from 4/7/24 to 6/29/24 was five times a week. A Review of her HHA visit notes for the weeks starting 4/7/24 and 4/14/24, revealed no documented evidence that an HHA provided care to CR9. During an interview on 4/25/24, at 8:58 a.m. the Administrator confirmed the above findings.

Plan of Correction:

How the specific findings will be corrected:
Documentation must be completed by the end of the work week.

Measures put in place or systemic changes made to ensure deficient practice will not recur:
1.All staff will be educated on timeliness of documentation by 5/9/2024
2.An Aide Visit Report will be run each Monday to confirm that all visit documentation is present for each aide visit.
Monitoring of corrective actions:
1. The HHA Coordinator will contact any aides that do not have their documentation from the prior week completed. They will be required to come into the office to complete their notes.
2. 20% of charts with hospice aide services provided will be audited monthly for compliance with documentation of aide visit present. Charts will continue to be audited until a goal of 95% compliance is achieved for three consecutive months, to begin May 1, 2024
3. If the goal is not met in three months, a performance improvement plan will be initiated.

Responsible individual for implementing and monitoring corrective actions:
The Program Director is responsible for implementing and monitoring the plan of correction.

How and when monitoring will be conducted and to whom results will be reported:
Clinical record review will be conducted monthly and results reported to the Program Director and included in quarterly QAPI minutes. All audit results will also be reported to the Governing Body on a quarterly basis.



418.108(c)(6) STANDARD
INPATIENT CARE PROVIDED UNDER ARRANGEMENTS

Name - Component - 00
[If the hospice has an arrangement with a facility to provide for short-term inpatient care, the arrangement is described in a written agreement, coordinated by the hospice and at a minimum specifies-]
(6) A method for verifying that the requirements in paragraphs(c)(1) through (c)(5) of this section are met.



Observations: Based on review of agency agreements (AG), and staff interviews (EMP) the agency failed to maintain documentation verifying the training of staff within facilities contracted for inpatient care for three (3) of three (3) agreements reviewed. Findings include: A review of facility agreements (AG) on 4/25/24 at 12:10 p.m. revealed: AG1: agreement dated 2/22/24, titled Hospices Services Agreement revealed: Article X (10) Orientation and In-Service Education: Section 10.1 Hospice staff shall orient Facility staff furnishing care to Residents regarding Hospice principles and philosophy. The orientation and in-service education programs will provide Facility staff with an understanding of hospice and their responsibilities under this agreement. AG2: agreement dated 11/22/23, titled Hospices Services Agreement revealed: Article X (10) Orientation and In-Service Education: Section 10.1 Hospice staff shall orient Facility staff furnishing care to Residents regarding Hospice principles and philosophy. The orientation and in-service education programs will provide Facility staff with an understanding of hospice and their responsibilities under this agreement. AG3 agreement dated 6/8/22, titled Hospices Services Agreement revealed: Article X (10) Orientation and In-Service Education: Section 10.1 Hospice staff shall orient Facility staff furnishing care to Residents regarding Hospice principles and philosophy. The orientation and in-service education programs will provide Facility staff with an understanding of hospice and their responsibilities under this agreement. During an interview on 4/25/24, at 1:06 p.m. the Administrator (EMP) indicated they have a binder that has copies Orientation and Inservice Education, and the binder failed to contain documentation of Orientation and Inservice education for the above agreements.

Plan of Correction:

How the specific findings will be corrected:
Hospice staff shall orient Facility staff furnishing care to Residents regarding Hospice principles and philosophy. The orientation and in-service education programs will provide Facility staff with an understanding of hospice and their responsibilities under this agreement.

Measures put in place or systemic changes made to ensure deficient practice will not recur:
Liaisons assigned to the facility will create a schedule for providing orientation to the facility staff.

All three facilities noted have received orientation to the hospice philosophy as of 5/1/24.

Monitoring of corrective actions:
1. The Program Director will review monthly the receipt of documentation that all scheduled facility orientation has been completed.
2. Non-compliance will result in progressive disciplinary action.

Responsible individual for implementing and monitoring corrective actions:
The Program Director is responsible for implementing and monitoring the plan of correction.

How and when monitoring will be conducted and to whom results will be reported:
Documentation of all completed facility orientation will be tracked and reported to the Program Director and included in quarterly QAPI minutes.




Initial Comments:

Based on the findings of an onsite unannounced state relicensure survey completed 4/25/2024, Caring Hospice Services - Monroeville 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 4/25/2024, Caring Hospice Services - Monroeville was found to be in compliance with the requirements of 35 P.S. 448.809 (b)
Plan of Correction: