QA Investigation Results

Pennsylvania Department of Health
AMEDISYS HOSPICE OF GREATER PITTSBURGH
Health Inspection Results
AMEDISYS HOSPICE OF GREATER PITTSBURGH
Health Inspection Results For:


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Initial Comments:

Based on the findings of an onsite unannounced State relicensure survey completed April 5, 2024, Amedisys Hospice of Greater Pittsburgh 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 survey completed April 5, 2024, Amedisys Hospice of Greater Pittsburgh 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:




418.60(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 review of agency policy and procedure, patient visit observations (OBV) and staff (EMP) interview, the agency failed to ensure staff followed accepted standards of practice to prevent the transmission of infections, including the use of standard precautions for one (1) of three (3) observations conducted. (Observation 1).

Findings include:

Review of agency policy/procedure on 4/2/34 at approximately 11:00 a.m. to 12:00 p.m. revealed: " Hand Hygiene. " Last review date 6/22/22. Purpose: To prevent the spread of infection by contaminated hands ...Guidelines:...4. Perform hand hygiene as follows ...e. After contact with body fluids or excretions ...non-intact skin and wound dressings.

Review of agency policy/procedure on 4/5/24 at approximately 11:45 a.m. 10:00 a.m. to 11:00 a.m. revealed: " Application of a Wound Care Dressing. " ...Procedure: 8. Hold soiled dressing hand and remove glove to wrap inside out around dressing. Repeat with second glove and discard in disposable bag. 9. Perform hand hygiene.

Observation of patient home visit (Observation 1) conducted on 4/3/24 between approximately 8:00 a.m. and 8:40 a.m. revealed...Skilled nurse (EMP1) entered patient home. Patient was sitting at the kitchen table with feet propped up on a pillow that was on a foot stool. EMP1 placed barrier pad on a bedside table and placed bag on barrier. EMP1 performed hand washing at the kitchen sink. Donned gloves. A barrier pad was placed under the patient 's feet. Gloves removed and used hand sanitizer. EMP1 gathered supplies and donned gloves. EMP1 picked scissors off of the table and removed the bandage that was on left foot/heel. Placed old dressing on the pad that was on the foot stool. Patient 's caregiver picked up old dressing and disposed of it in patient 's trash receptacle. EMP1 opened a
4 x 4 gauze dressing package and opened a bottle of wound cleanser. EMP1 poured wound cleanser on the 4 x 4 gauze dressing and cleansed left inner heel wound. EMP1 replaced the cap on the wound cleanser bottle. EMP1 performed an assessment of the patient's lower leg and foot. Retrieved Medihoney tube from the table, opened a non-stick pad package, applied the Medihoney to the non-stick pad. Placed a roll of tape and a roll of Kerlix on the pad that was on the foot stool. Wrapped the left foot wound with the Kerlix roll. Taped the Kerlix in place. Tape fell to the floor, EMP1 picked it up and placed in on the counter. Removed gloves. Washed hands at the sink.

Findings were reviewed on 4/3/24 at approximately 9:30 a.m. with the Director of Operations.










Plan of Correction:

Plan of Correction Monroeville -

TAG L579 418.60(a) Prevention.

As described in more detail below, Amedisys Hospice has implemented corrective actions aimed at reinforcing its policies and practices for maintaining and documenting an effective infection control program that protects patients, families, visitors, and hospice personnel by preventing and controlling infections and communicable diseases.

1. Corrective Action / Preventing Reoccurrence: On 4/11/2024, upon notification of deficiency, 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 current and future patients receive services in accordance with federal and state regulations; policy and procedures of the agency; and receive services in accordance with standards for Infection Control and to ensure the hospice agency is following proper standards of practice to prevent the transmission of infection and communicable diseases, including the use of standard and transmission-based precautions. The Director of Operation and Clinical Manager will provide oversight and implemented the corrective action plan steps, as outlined herein.

a. Education/Training: On 4/16/2024, the Clinical Manager (Registered Nurse) provided comprehensive re-education and remediation for all staff on appropriate agency policies related to deficient areas:

Review of Agency Policies and Procedures:

o PCP -001 Hand Hygiene

o PCP -002 Bag technique

o PCP -003 Decontamination of Reusable equipment

o ICS -001 Standard Precautions

o ICS-002 Transmission-Based Precautions

o WC-001 Provision of wound care

b. Implementation & Monitoring:

Initiated on 4/16/2024, a process was implemented requiring that the Director of Nursing and clinical manager will sign off on bag technique and handwashing and decontamination of the reusable equipment competencies for each clinician providing care to hospice patients this will be completed.

To ensure continued compliance with infection control measures, the Clinical Manager, or her/his RN designee, will complete on-site evaluations to observe five (5) clinical staff members per month until an on-site evaluation for each member has been completed. Any deficiency with an on-site visit will require immediate remediation (infection control education & sign-off regarding the competency), followed by an onsite visit within 48 hours of sign-off. This process will continue monthly until 100% compliance has been maintained for 1 quarter.

2. Person Responsible. The Clinical Manager (Registered Nurse)/Director of Operation 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.

3. Completion Date: 5/10/2024


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 an observational tour (OBV) and staff (EMP) interview, it was determined that the agency failed to be primarily engaged in providing care and services in a manner that is consistent with accepted standards of practice related to the storage of medical supplies for one (1) of one (1) observation. (Observation 1).

Findings include:

During (OBV1) tour of the agency office on 4/2/24 between approximately 10:15 a.m. and 10:30 a.m. the supply room was observed. Observation revealed the following findings:

-Six (6) Covidien catheter draining bags with an expiration date of 1/31/24.
-Eight (8) enteral pump sets, tube feed bags with expiration date of 8/28/22.
-Fifteen (15) Kangaroo Pump sets, feeding bags with expiration date of 8/31/22.
-Fifteen (15) 1 ml syringes 2g gauge X 1 inch with expiration date of 11/20/19.
-Four (4) 1 ml syringe 25 X 5/8 undated.

A review of the findings was conducted on 4/2/24 at approximately 10:35 a.m. with the agency Director of Operations.











Plan of Correction:

TAG L0652 418.110(c)Services

Amedisys Hospice has implemented corrective actions aimed at reinforcing its policies and practices for providing services in an manner that is consistent with accepted standards of practice: for nursing services, medical social work, Physician services, counseling, hospice aide, volunteer, homemakers, Physical therapy, Occupational therapy, speech- language therapy and short term inpatient care and medical supplies (including drugs and biologicals and medical appliances)

1. Corrective Action / Preventing Reoccurrence: Initiated on 4/11/2024, the Clinical Manager/Director of Operation. provided oversight and implemented the corrective action plan concerning hospice services.

a. Education/Training: 4/16/2024 the director of Operation/or Clinical Managed will review.

Review of Agency Policies and Procedures:

o EC-006 Amedisys Formulary medical supply/Device recalls

o EC-003 Medical Equipment and Management and calibration

b. Implementation & Monitoring: Effective 4/16/2024, the Clinical Manager/Business office manager and Director will audit the supply room for expired supplies weekly to ensure all supplies are not expired. This will occur weekly until 100% compliance has been maintained for 1 month then it will be completed monthly ongoing.

c. Person Responsible. The Clinical Manager/ Director of Operation is responsible for confirming the above requirements are met and documented. All findings will be reported at the quarterly QAPI committee meeting and Governing Body as appropriate, but at least annually.

d. Completion Date: 5/10/2024


Initial Comments:

Based on the findings of an onsite unannounced State relicensure survey completed April 5, 2024, Amedisys Hospice of Greater Pittsburgh 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 April 5, 2024, Amedisys Hospice of Greater Pittsburgh was found to be in compliance with the requirements of 35 P.S. 448.809 (b)





Plan of Correction: