QA Investigation Results

Pennsylvania Department of Health
ADVANTAGE HOME HEALTH AND HOSPICE WESTERN
Health Inspection Results
ADVANTAGE HOME HEALTH AND HOSPICE WESTERN
Health Inspection Results For:


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Initial Comments:



Based on the findings of an onsite Medicare recertification and State re-licensure survey completed April 30, 2024, Advantage Home Health and Hospice Western was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Condition of Participation: Home Health Agencies- Emergency Preparedness.





Plan of Correction:




Initial Comments:



Based on the findings of an onsite Medicare recertification and State re-licensure survey completed April 30, 2024, Advantage Home Health and Hospice Western 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:




418.56(b) STANDARD
PLAN OF CARE

Name - Component - 00
All hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire.



Observations: Based on review of clinical records (CR) and staff (EMP) interview, the hospice failed to follow the Hospice Plan of Care (POC) and/or Physician orders for frequency of services for five (5) of eleven (11) clinical records (CR #1, 3-5, and 11). The agency also failed to ensure that care provided followed an individualized written plan of care for two (2) of eleven (11) clinical records (CR#1 and 9). Findings include: Review of clinical records conducted April 23, 2024, between 12:00pm and 2:30pm and April 25, 2024, between approximately 9:00am and 1:30pm revealed the following: CR1, start of care (SOC) 3/7/24, benefit period reviewed 3/7/24-6/4/24. Hospice Plan of Care (POC) included chaplain frequency of 1 visit a month for 1 month, 2 visits a month for 2 months, effective 3/18/24. 2 Chaplain visits conducted first month on 3/19/24 and 4/2/24. CR3, SOC 3/8/24, benefit period reviewed 3/8/24-6/5/24. POC included skilled nurse frequency of 2 times a week for 12 weeks, 1 time a week for 1 week effective 3/11/24. 1 nursing visit conducted week of 3/31/24. POC included Hospice Aide frequency of 4 times a week for 12 weeks, 3 times a week for 1 week. 2 Aide visits conducted week of 3/31/24, and no visits conducted weeks of 4/7/24 or 4/14/24. POC included Social Worker frequency of 1 time a month for 1 month, 2 times a month for 2 months effective 3/13/24. 2 Social Worker visits on conducted 3/26/24 and 4/10/24. CR4, SOC 3/20/24, benefit period reviewed 3/20/24-6/17/24. POC included skilled nurse frequency of 2 times a week for 12 weeks effective 3/25/24. 1 nursing visit conducted weeks of 3/31/24, 4/7/24, and 4/14/24. POC included order for Chaplain evaluation. No evidence chaplain evaluation conducted. CR5, SOC 3/15/24, benefit period reviewed 3/15/24-6/12/24. POC included Hospice Aide frequency of 2 times a week for 12 weeks, 1 time a week for 1 week effective 3/15/24 changing to 3 times a week for 12 weeks and 2 times a week for 1 week effective 3/19/24. No aide visits conducted week of 3/5/24, 4 aid visits conducted week of 3/17/24, 4 aid visits conducted week of 3/24/24, no aide visits conducted weeks of 4/7/24, 4/14/24, or 4/21/24. CR11, SOC 12/21/23, benefit period reviewed 3/11/24-6/8/24. POC included skilled nurse frequency of 2 times a week for 13 weeks effective 3/11/24. 1 skilled nurse visit conducted weeks of 3/31/24 and 4/14/24. POC included Hospice Aide frequency of 5 times a week for 13 weeks effective 3/11/24. 4 aide visits conducted weeks of 3/17/24 and 3/31/24, 3 aide visits conducted week of 4/7/24, and no aide visits conducted week of 4/14/24. Interview with agency administrator on 4/25, 24 at approximately 12:00pm revealed that agency has had difficulty staffing aides and that one in particular had been not showing up to work. Exit interview with Administrator and Social worker/Volunteer Coordinator on April 25, 2024, at approximately 3:00pm confirmed findings.

Plan of Correction:

The Administrator or designee will educate all staff on agencies care planning process which talks patient specific frequencies policy week of 5/28/24.
The administrator or assigned designee will audit all new admission beginning week of 5/28/24 to assure patient specific Plan of Cares, and Patient specific frequencies. Will continue weekly until a compliance rate of 90 percent is met and then weekly x2 and then we be included in agency QAPI plan for continued monitoring.




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 home visit (HV) and staff (EMP) interview the skilled nurse failed to follow accepted standards of practice to prevent the transmission of infection for two (2) of three (3) Home Visits conducted (HV #1 and 2). Findings include: HV observation #1and 2 conducted on 4/24/24 at approximately 12:00pm with skilled nurse (SN) and home health aide (HHA) simultaneously. Patient presented with wounds to bilateral lower extremities. POC included orders for wound care to left and right shins. SN removed dirty dressing from wounds on both legs and proceeded to clean wounds, first on right leg, then on left leg without. SN failed to remove dirty gloves, perform hand hygiene, and don clean gloves after removal of dirty dressings. SN also worked between wounds on different legs, risking transfer of infection from one wound to the other. While assisting SN with patient positioning, HHA reached over patient with right gloved hand that had been used for patient care and touched opened wound on left shin, after wound had been cleansed by SN. SN failed to re-clean wound. Exit interview with Administrator and Social worker/Volunteer Coordinator on April 25, 2024, at approximately 3:00pm confirmed findings.

Plan of Correction:

Administrator or designee develop wound care procedure then will educate all staff on hand washing policy and wound procedure week of 5/28/24. The administrator or designee with make 2 supervisory visits with staff every 2 weeks to ensure staff are following policy and procedure for hand hygiene and wound care beginning week of 5/28/24. The Administrator or designee will monitor the outcomes Q2 weeks until compliance of 90% and then 1 additional time, then to be included in Agencies QAPI program for continued monitoring.




418.64(b)(1) STANDARD
NURSING SERVICES

Name - Component - 00
§418.64(b) Standard: Nursing services

§418.64(b)(1) The hospice must provide nursing care and services by or under the supervision of a registered nurse. Nursing services must ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and updated assessments.

Observations: Based on review of agency policy, clinical records (CR), and staff (EMP) interview the skilled nurse failed to ensure that wound care was documented in accordance with hospice policy for two (2) of eleven (11) CR reviewed. (CR # 1 and 2). Findings include: Review of agency policy on 4/23/24 at approximately 12:00pm revealed: "Wound Measurement Policy, A. All patients will be assessed upon admission for wounds, b. Presence of skin impairment and any type of wound, including pressure ulcers... B. Wound Measurement...2. Pressure ulcers and other wounds will be measured and reassessed by a nurse minimally weekly to assess for response to treatment interventions., C. Documentation will occur in POC and subsequent visit notes..." Review of clinical records conducted April 23, 2024, between 12:00pm and 2:30pm and April 25, 2024, between approximately 9:00am and 1:30pm revealed the following: CR1, start of care (SOC) 3/7/24, benefit period reviewed 3/7/24-6/4/24. Plan of care (POC) and skilled nurse visit notes identified 3 wounds. No documentation of wound measurements upon start of care, or at any nurse visits weeks of 3/7/24, 3/10/24, 3/17/24, 3/24/24, 4/7/24, or 4/14/24. Wound measurements documented once between dates of review, on 4/4/24. CR2, SOC 4/16/24, benefit period reviewed 4/16/24-7/14/24. POC included orders for wound care to bilateral lower legs. Subsequent visit notes included documentation of wounds. Initial comprehensive assessment failed to identify or assess any wounds. Exit interview with Administrator and Social worker/Volunteer Coordinator on April 25, 2024, at approximately 3:00pm confirmed findings.

Plan of Correction:

Administrator or assigned designee with re-educate all staff on agencies current wound measurements policy week of 5/28/2024, Administrator or assigned designee will audit all wound care charts weekly beginning week of 5/28/2024 to assure wounds are being assessed and measured per policy. Weekly until a compliance of at least 90% is reached then x2 and then will continue to be monitored in our agencies QAPI plan


418.100(c)(1) STANDARD
SERVICES

Name - Component - 00
(1) A hospice must be primarily engaged in providing the following care and services and must do so in a manner that is consistent with accepted standards of practice:
(i) Nursing services.
(ii) Medical social services.
(iii) Physician services.
(iv) Counseling services, including spiritual counseling, dietary counseling, and bereavement counseling.
(v) Hospice aide, volunteer, and homemaker services.
(vi) Physical therapy, occupational therapy, and speech-language pathology services.
(vii) Short-term inpatient care.
(viii) Medical supplies (including drugs and biologicals) and medical appliances.


Observations: Based on review of clinical records (CR) and staff (EMP) interview, the hospice failed to engage in providing occupational therapy for one (1) of eleven (11) clinical records reviewed (CR#10). Findings include: Review of clinical records conducted April 23, 2024, between 12:00pm and 2:30pm and April 25, 2024, between approximately 9:00am and 1:30pm revealed the following: CR10, start of care (SOC) 1/10/23, benefit periods reviewed 1/10/23-5/3/24.Clinical record included an order for Occupational Therapy Evaluation dated 7/24/23. No evidence in clinical record that therapy evaluation was conducted. Exit interview with Administrator and Social worker/Volunteer Coordinator on April 25, 2024, at approximately 3:00pm confirmed findings.

Plan of Correction:

Administrator or designee will educate all staff on updated physician orders policy week of 5/28/24. Administrator will educate all contract staff on updated physician order policy and completing documentation as ordered week of 6/3/24. Administrator or designee will audit assess and evaluation orders pertaining to therapy evaluations weekly beginning week of 5/28/24 to assure timely follow up until a goal of 95% percent is reached then x2 weeks and will continue to be monitored in agencies QAPI program.


Initial Comments:



Based on the findings of an onsite Medicare recertification and State re-licensure survey completed April 30, 2024, Advantage Home Health and Hospice Western 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 onsite Medicare recertification and State re-licensure survey completed April 30, 2024, Advantage Home Health and Hospice Western was found to be in compliance with the requirements of 35 P.S.448.809 b.




Plan of Correction: