Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey completed January 9, 2024, Heritage 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:
418.113(b)(4) STANDARD
Policies/Procedures-Volunteers and Staffing
Name - Component - 00
§403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5).
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]
(6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.
*[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency.
*[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.
Observations:
Based on review of agency Emergency Preparedness policies and procedures the agency failed to develop policies for the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency for one (1) of one (1) Emergency Preparedness program developed by the agency.
Findings included:
Agency Emergency Preparedness Program reviewed on January 3, 2024, at approximately 2:30pm failed to include policies or procedures for the use of volunteers or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency for one (1) of one (1) Emergency Preparedness program developed by the agency.
During interview on January 3, 2024, at approximately 3:00pm Program Director stated, " I was not aware that needed to be included..."
Exit interview with Program Director, Clinical Directors, Administrative Manager, Administrative Assistant, and 8 members of the regional team linked in on a call confirmed findings.
Plan of Correction:What action will we take to correct the deficiency cited?
PD will add to the current EPP the following process:
The PD will include in vital contacts of EPP the contact info for ESAR-VHP (The Emergency System for Advance Registration of Volunteer Health Professionals) and will establish a contact for the agency by February 9, 2024.
In the event a spontaneous volunteer arrives on site, the volunteer will be directed to the Emergency Manager (PD or designee). The Emergency Manager will appoint a Clinical Manager and an Administrative Manager. The Administrative Manager or designee will gather volunteer's information, including basic demographics, licensing and credentials, agency the volunteer represents if applicable, and capacity or role the volunteer is requesting to work. No volunteers not directly employed by the agency will be able to perform in any type of skilled capacity unless verification of licensing/credential/credential level via an emergency volunteer organization (ie: ESAR-VHP) has occurred prior.
The volunteer will see the Emergency Manager or designee for orientation to the situation/plan and duties and report off to the Emergency Manager or designee with any updates or before ending their time on site.
The agency will keep documentation of the volunteer's demographics, any verifications that occurred and duties performed.
Who is responsible to implement the corrective action? Program Director will include information in EPP and be responsible for educating all staff on the process by February 16, 2024.
When will the corrective action be implemented? Immediately and ongoing
What is the monitoring process we will put into place to ensure implementation and effectiveness of this corrective action plan? The updated EPP will be submitted to QAPI Committee for review and acceptance in next QAPI meeting in February 2024. Program Director or designee ensures Heritage Hospice is educated and equipped to address and handle any emergency help that comes on site during the emergency with a review of the EPP minimally every 2 years and education provided annually for all staff, including contracted employees. The agency will continue the review as part of its quality assurance and performance improvement (QAPI) program and will be reported quarterly to the corporate governing body's compliance committee.
418.113(d)(1) STANDARD
EP Training Program
Name - Component - 00
§403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1).
*[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:]
(1) Training program. The [facility] must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures.
*[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles.
(ii) Demonstrate staff knowledge of emergency procedures.
(iii) Provide emergency preparedness training at least every 2 years.
(iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others.
(v) Maintain documentation of all emergency preparedness training.
(vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and
procedures.
*[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) After initial training, provide emergency preparedness training every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures.
(iv) Maintain documentation of all emergency preparedness training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures.
*[For PACE at §460.84(d):] (1) The PACE organization must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency.
(iv) Maintain documentation of all training.
(v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures.
*[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role.
(ii) Provide emergency preparedness training at least annually.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.
*[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following:
(i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment.
(v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures.
*[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following:
(i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of the training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures.
*[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.
Observations:
Based on review of agency personnel files (PF), the agency failed to maintain documentation that demonstrated staff knowledge of emergency procedures initially and at least every two years for two (2) of two (2) individuals providing services under arrangement. PF#7 and 8.
Findings included:
Review of PF on January 3, 2024, at approximately 9:15am revealed:
PF7, contract effective with agency 7/12/2022, failed to include evidence of agency emergency preparedness training and staff knowledge initially upon contract with agency or annually thereafter.
PF8, contract effective with agency 7/12/2022, failed to include evidence of agency emergency preparedness training and staff knowledge initially upon contract with agency or annually thereafter.
Review of contract for therapy services on January 3, 2024, at approximately 10:00am revealed:
PHYSICAL AND OCCUPATIONAL THERAPY SERVICES AGREEMENT, THIS PHYSICAL THERAPY and OCCUPATIONAL THERAPY SERRVICES AGREEMENT ("Agreement") is made and entered into this 12th day of July, 2022 ... AGREEMENT ...2. Hospice Authority 2.1 Hospice shall specify the education, training, and qualifications required by all personnel providing care under this agreement...
Exit interview with Program Director, Clinical Directors, Administrative Manager, Administrative Assistant, and 8 members of the regional team linked in on a call confirmed findings.
Plan of Correction:What action will we take to correct the deficiency cited? Education from Program Director to Administrative Manager. Administrative Manager, or designee will ensure employees and contracted employees receive training on the EPP on hire, if policies or training changes and minimally every 1 year afterward.
Who is responsible to implement the corrective action? Program Director
When will the corrective action be implemented? By Feb 1, 2024, Program Director will educate Administrative Manager on regulation/requirement.
By Feb 16, 2024, Program Director or designee will educate all contracted employees (or designee) on the EPP and require an attestation be signed by each contractor to verify receipt of EPP training and maintained as part of the contracted employees personnel file by February 29, 2024. Ongoing the contracted employees will be oriented by Program Director or designee before working for the agency.
Administrative Manager, or designee will perform a 100% audit on the contracted employees' personnel files (who have worked for Heritage Hospice in 2023 or 2024) by Feb 29, 2024, to ensure 100% compliance.
What is the monitoring process we will put into place to ensure implementation and effectiveness of this corrective action plan? Once threshold is met, Administrative Manager, or designee will perform a 100% audit each quarter x 4 quarters and then yearly ongoing to ensure compliance is maintained.
Ongoing the contracted employees will be oriented by Program Director or designee before working for the agency and audited for compliance as stated above. The agency will continue the review as part of its quality assurance and performance improvement (QAPI) program and will be reported quarterly to the corporate governing body's compliance committee.
Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey completed January 9, 2024, Heritage 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:
418.56(c)(4) STANDARD
CONTENT OF PLAN OF CARE
Name - Component - 00
[The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following:]
(4) Drugs and treatment necessary to meet the needs of the patient.
Observations:
Based on review of agency policy/procedure, home visit observation (OBS) and clinical records (CR), the agency failed to ensure the patient plan of care included indications for PRN (pro re nata) (as needed) medications for eight (8) of fourteen (14) CR reviewed (CR1-3, 5, 6, 10, 11, & 13.) The agency also failed to ensure the patient plan of care included orders for treatments necessary to meet the needs of the patient for four (4) of fourteen (14) CR reviewed (CR5-7, & 9.)
Findings included:
Review of agency policy/procedure on January 3, 2024, at approximately 12:00pm revealed:
PC.M50 MEDICATION - ORDERS ... Procedure: ... 1. Both telephone and written orders for medications are documented in the patient's clinical record and include: h. Special instructions or precautions, if indicated;
"PC. P50 PLLAN OF CARE, Procedure: ...6. The Hospice written interdisciplinary plan of care is developed and individualized for each patient and family, ... and includes all services necessary for palliation and management of the terminal illness and related conditions, including the following: ... h. Treatments, drugs, biologicals, and interventions to manage pain and symptoms of the terminal illness: including dosage/frequency/route when applicable; ..."
"PC. W10 Wound Assessment and Evaluation... Procedure: ...13. Wound care and/or management must have an MD order and be documented on the hospice patient's interdisciplinary plan of care."
Review of CR on 1/5/24 between 10:15am and 3:00pm and on 1/8/24 between 9:00am and 1:30pm revealed:
CR1, start of services 5/11/23, time period reviewed 5/11/23-6/9/23. Patient medication list included Motrin IB 400mg (milligram) PRN every 6 hours PO (by mouth) and Tylenol Extra Strength 500mg 2 tablets PRN every 6 hours PO. Medications failed to include indications for PRN administration.
CR2, start of services 6/30/22, time period reviewed 5/26/23-7/6/23. Patient medication list included Ativan 1mg tablet PRN every hour PO, Morphine Sulfate (Concentrate) 20mg/ml (milliliter) 10mg PRN every hour sublingual (under tongue). Medications failed to include indications for PRN administration.
CR3, start of services 5/22/23, time period reviewed 11/18/23-12/19/23, and bereavement period 12/19/23-1/5/24. Patient medication list included Ativan Intensol (2mg/ml) 0.5 ml PRN every hour PO, Morphine Sulfate (Concentrate) 20mg/ml 0.5 ml PRN every hour PO, Acetaminophen Rectal Suppository 650mg PRN every 4 hours PR (per rectum), Levsin tablet 0.125mg tablet PRN every 4 hours PO, Ducolax Rectal Suppository 10mg daily PR PRN, Lorazepam 0.5mg tablet PRN every hour PO, MiraLax packet 17G (gram) 1 scoop daily PO PRN, and oxyCODONE HCL 5mg capsule 2 capsules PRN every 4 hours PO. Medications failed to include indications for PRN administration.
CR5, start of services 6/30/2023, time period reviewed 6/30/23-1/5/24. Patient medication list included HYDROcodone-Acetaminophen 5-325mg tablet PRN every 6 hours PO. Medication failed to include indications for PRN administration. Home visit conducted on 1/4/23 at approximately 10:30am revealed patient wearing knee-high antiembolism stockings on both feet, Plan of care (POC) failed to include order for stockings. 12/7/23 skilled nurse note stated "using brace on left hand," POC failed to include order for hand brace. Observation revealed a bordered gauze dressing to patient coccyx dated 1/3/24. During interview on 1/4/24 at approximately 11:00am skilled nurse reported that the patient has an open area to coccyx and that the dressing is being changed every 5 days and as needed for drainage. POC failed to contain evidence of wound care orders.
CR6, start of services 7/19/2023, time period reviewed 10/17/23-1/5/24. Patient medication list included Cherrytussin 1-2 tablespoons PRN every 4 hours PO and Zofran 4 mg PRN every 8 hours PO. Medications failed to include indications for PRN administration. POC and medication list included insulin to be administered on a sliding scale (insulin dose determined by result of blood glucose check) three times a day, POC failed to include orders for blood glucose testing.
CR7, start of services 10/2/23, time period reviewed 10/20/23- 1/8/24. Initial comprehensive assessment dated 10/20/24 included documentation of wound located on patient coccyx. POC failed to include orders for wound care.
CR9, start of services 3/25/23, time period reviewed 3/25/23-5/5/23, and bereavement period 5/5/23-1/8/24. POC and medication list included insulin to be administered on a sliding scale (insulin dose determined by result of blood glucose check) before meals and at bedtime, POC failed to include orders for blood glucose testing. Initial comprehensive assessment dated 3/25/23 included documentation of wound located on patient sacrum, nursing note dated 3/29/23 included documentation of new wound to left lower leg, nursing note dated 5/3/23 included documentation of new wounds to left upper and left lower back, crease of buttock and right thigh, and also crease of buttock and left thigh. POC failed to include orders for wound car for all documented wounds.
CR10, start of services 8/3/23, time period reviewed 8/3/23-8/22/23. Patient medication list included Refresh Opthalmic Solution 1.4-0.6 percent PRN every 4 hours OP 1 drop PRN every 4 hours to both eyes, Odansetron Disintegrating 4mg tablet PRN every 6 hours PO, Oxyfast 20mg/ml 10ml PRN every hour PO, Mucinex 600mg Tablet Extended Release 12 hour 1 tablet every 12 hours PO PRN, LORazepam Intensol Concentrate 2mg/ml 1 mg PRN every hour PO, Levsin tablet 0.125mg tablet PRN every 4 hours PO, and Haloperidol Lactate Concentrate 2mg/ml 1 mg PRN every hour PO. Medications failed to include indications for PRN administration.
CR11, start of services 8/25/23, time period reviewed 11/13/23- 1/8/24. Patient medication list included Acetaminophen-Codeine #4 300-60mg 1 tablet twice a day PO PRN, Proventil HFA Inhaler Aerosol Solution 108 (90 base) mcg (micrograms)/act (actuation) 2 puffs PRN every 6 hours INH (inhalation), Ibuprofen 200mg tablet 400mg twice a day PO as needed, and Docusate Sodium 100mg capsule twice a day PO as needed. Medications failed to include indications for PRN administration.
CR13, start of services 11/17/23, time period reviewed 11/17/23-1/8/24. Patient medication list included Acetaminophen Chewable 325mg 650 mg PRN every 6 hours PO. Medication failed to include indications for PRN administration.
Exit interview with Program Director, Clinical Directors, Administrative Manager, Administrative Assistant, and 8 members of the regional team linked in on a call confirmed findings.
Plan of Correction:What action will we take to correct the deficiency cited?
Clinical Directors/designee will provide 2 educations under L0549
1. Medication and treatment orders education
Clinical Directors education to 100% of nursing staff will include: the necessity to enter all orders into the medical record, PRN indications/drug/dose/frequency with focus on insulin orders and specific wound care orders for each patient. Also specific to wound education, location of wound, treatment and frequency of wound care.
2. Facility Collaboration Education
Clinical Directors education to 100% of nursing staff will include: Utilization of nursing treat careplan to ensure there are specific directions regarding the collaboration of care between hospice and facility.
Who is responsible to implement the corrective action?
Clinical Directors/Designee
When will the corrective action be implemented?
POC in service scheduled for week of Feb 5, 2024 for all nursing staff. Clinical Director audits will begin the week of Feb 12, 2024, once all nursing staff is educated.
What is the monitoring process we will put into place to ensure implementation and effectiveness of this corrective action plan?
Clinical Directors /or designee will audit 100 % of patients biweekly at the time of the IDG. Audits to include: All current medications are entered in medical record, PRN medications have a drug/dose/indication/frequency and route on the MD order, specific orders for wound care including, location, treatment and frequency are entered, sliding scale insulin contain order for blood sugar checks, nursing treatment care plans are utilized for all facility patients.
Once 95% documentation compliance is met and maintained for 3 consecutive months, 20% of patient charts will be audited monthly , for a continued documentation compliance of 95% for 2 additional consecutive months. 1:1 education will be provided to any nursing staff not meeting thresholds. The agency will continue the review as part of its quality assurance and performance improvement (QAPI) program and will be reported quarterly to the corporate governing body's compliance committee.
418.56(c)(5) STANDARD
CONTENT OF PLAN OF CARE
Name - Component - 00
[The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following:]
(5) Medical supplies and appliances necessary to meet the needs of the patient.
Observations:
Based on review of agency policy and procedure, clinical records (CR), and home visit observation (OBS) the agency failed to ensure the patient plan of care included medical supplies and appliances necessary to meet the needs of the patient for three (3) of fourteen (14) CR reviewed (CR 5-7.)
Findings included:
Review of agency policy on 1/8/23 at approximately 2:00pm revealed:
"PC. P50 PLLAN OF CARE, Procedure: ...6. The Hospice written interdisciplinary plan of care is developed and individualized for each patient and family, ... and includes all services necessary for palliation and management of the terminal illness and related conditions, including the following: ... k. Medical supplies and appliances, durable medical equipment necessary to meet needs; ..."
Review of CR on 1/5/24 between 10:15am and 3:00pm and on 1/8/24 between 9:00am and 1:30pm revealed:
CR5, start of services 6/30/2023, time period reviewed 6/30/23-1/5/24. Home visit observation conducted on 1/4/24 at approximately 10:00am revealed the following equipment to be in use by the patient or in the unshared room of the patient, and not included on the Plan of Care (POC.) Concave mattress, fall mats x2, antiembolism stockings, bedside table, elevated toiled chair, wheelchair cushion, and hospital bed. Review of CR revealed the patient also was to have a brace applied to left hand and a wedge pillow, which were not included in the POC. The POC included a chair alarm, elevated leg footrests for wheelchair, and low air loss mattress, none of which were present during home visit observation.
CR6, start of services 7/19/2023, time period reviewed 10/17/23-1/5/24. Home visit observation conducted on 1/4/24 at approximately 1:00pm revealed the following equipment to be in use by the patient or in the room of the patient, and not included on the Plan of Care (POC.) Hospital bed, wheelchair cushion, wheelchair leg rests, bed side table, heel protectors, and colostomy supplies.
CR7, start of services 10/2/23, time period reviewed 10/20/23- 1/8/24. POC revealed patient receiving wound care. Initial comprehensive assessment dated 10/20/23 documented wound to coccyx. POC failed to include wound care supplies.
Exit interview with Program Director, Clinical Directors, Administrative Manager, Administrative Assistant, and 8 members of the regional team linked in on a call confirmed findings.
Plan of Correction:What action will we take to correct the deficiency cited?
Clinical Directors/designee will provide 1 education under L0550
1. Supplies and DME
Clinical Directors education to 100% of nursing staff will include: patient specific supplies and all current DME are present on the POC. RN documentation on the General Clinical tab within the patients medical record will reflect all orders, changes and discontinuation of supplies and DME. RN to document supplies and DME at each visit.
Who is responsible to implement the corrective action?
Clinical Directors/designee
When will the corrective action be implemented?
POC in service scheduled for week of Feb 5, 2024 for all nursing staff. Clinical Director audits will begin the week of Feb 12, 2024, once all nursing staff is educated.
What is the monitoring process we will put into place to ensure implementation and effectiveness of this corrective action plan?
POC in service scheduled for week of Feb 5, 2024 for all nursing staff. Clinical Director audits will begin the week of Feb 12, 2024, once all nursing staff is educated to ensure all patient specific supplies and all current DME are present on the POC.. Once 95% documentation compliance is met and maintained for 3 consecutive months, 20% of patient charts will be audited monthly , for a continued documentation compliance of 95% for 2 additional consecutive months. 1:1 education will be provided to any nursing staff not meeting thresholds. The agency will continue the review as part of its quality assurance and performance improvement (QAPI) program and will be reported quarterly to the corporate governing body's compliance committee.
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/procedure, home visit observation (OBS), and clinical records (CR), the agency failed to ensure skilled nurses followed agency policy for wound evaluation for three (3) of three (3) CR reviewed with wounds (CR 5, 7, & 9.)
Findings included:
Review of agency policy/procedure on January 3, 2024, at approximately 12:00pm revealed:
"PC. W10 Wound Assessment and Evaluation... Policy: Assessment and evaluation of skin and documentation of wounds occurs on admission to hospice, at the first sign of a wound, and at weekly intervals. The assessment, evaluation, and plan of care should be clearly documented. ...3. Wounds are reassessed, including measurements, at a minimum of weekly or more often as determined by the MD. This includes but is not limited to; dressing change competed by RN or witnessed by the RN during time of visit. If the facility staff typically complete wound care, the hospice RN will schedule a visit around wound care and or dressing changes schedule so that she/he is present and can assess the wound, including wound measurements, description of wound and wound care dressing no less frequently than weekly..."
Review of CR on 1/5/24 between 10:15am and 3:00pm and on 1/8/24 between 9:00am and 1:30pm revealed:
CR5, start of services 6/30/2023, time period reviewed 6/30/23-1/5/24. Home visit observation conducted on 1/4/24 at approximately 10:30am revealed bordered gauze dressing date 1/3/23 on patient coccyx. CR review revealed no wound measurements documented weeks of 12/17/23, 12/25/32, or 12/31/23. Interview with nurse on 1/4/32 at approximately 11:00am confirmed wound to be "excoriated area on coccyx with a slit approximately 2 cm long..."
CR7, start of services 10/2/23, time period reviewed 10/20/23- 1/8/24. CR included documentation of wound upon initial comprehensive assessment dated 10/20/23. Documentation noted "tunneling 1:00 per caregiver." No documentation of measurement of depth of tunneling or visualization of wound by hospice skilled nurse.
CR9, start of services 3/25/23, time period reviewed 3/25/23-5/5/23, and bereavement period 5/5/23-1/8/24. CR included documentation of sacral wound upon initial comprehensive assessment dated 3/25/23, CR failed to include wound measurements of sacral wound upon initial assessment, weeks of 3/26/23, 4/2/23, 4/9/23, 4/23/23, and 4/30/23. New wound documented to left lower leg on 3/29/23. CR failed to include wound measurements of left lower leg week of 4/9/23. New wounds documented 5/3/23 to left upper back, left lower back, crease of buttock/left thigh, crease of buttocks/right thigh. No wound measurements documented to left upper back, crease of buttock/left thigh, crease of buttocks/right thigh.
Exit interview with Program Director, Clinical Directors, Administrative Manager, Administrative Assistant, and 8 members of the regional team linked in on a call confirmed findings.
Plan of Correction:What action will we take to correct the deficiency cited?
Clinical Directors/designee will provide 2 educations under L0591
1. Regional Compliance Nurse care plan education
Regional Compliance Nurse provided education to all nursing staff on resources for wound care, Heritage Hospice Policy and Procedures regarding wound care documentation.
2. Facility Collaboration Education
Clinical Directors education to all nursing staff will include: Utilization of nursing treat care plan to ensure there are specific directions regarding the collaboration of care between hospice and facility.
Who is responsible to implement the corrective action?
Clinical Directors /designee
When will the corrective action be implemented?
RCN education given to staff on 1/29/2024.
POC in service scheduled for week of Feb 5, 2024 for all nursing staff. Clinical Director audits will begin the week of Feb 12, 2024, once all nursing staff is educated.
What is the monitoring process we will put into place to ensure implementation and effectiveness of this corrective action plan.
Clinical Directors/designee will audit 100 % of patients biweekly at the time of the IDG. Audits to include: specific wound documentation regarding weekly measurements per nursing best practice, and utilization of the nursing treatment care plans are entered for all facility patients to ensure collaboration of care
Once 95% documentation compliance is met and maintained for 3 consecutive months, 20% of patient charts will be audited monthly , for a continued documentation compliance of 95% for 2 additional consecutive months. 1:1 education will be provided to any nursing staff not meeting thresholds. The agency will continue the review as part of its quality assurance and performance improvement (QAPI) program and will be reported quarterly to the corporate governing body's compliance committee.
418.64(d)(1) STANDARD
COUNSELING SERVICES
Name - Component - 00
Counseling services must include, but are not limited to, the following:
(1) Bereavement counseling. The hospice must:
(i) Have an organized program for the provision of bereavement services furnished under the supervision of a qualified professional with experience or education in grief or loss counseling.
(ii) Make bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/MR when appropriate and identified in the bereavement plan of care.
(iii) Ensure that bereavement services reflect the needs of the bereaved.
(iv) Develop a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery. A special coverage provision for bereavement counseling is specified in §418.204(c).
Observations:
Based on review of agency policy/procedure, clinical records (CR), and Employee (EMP) interview, the agency failed to ensure bereavement services provided per agency policy for three (3) of four (4) bereavement records reviewed (CR 3,9, & 10.)
Findings included:
Interview with Program director, Regional Bereavement Coordinator, and Director of Support Services on 1/3/24 at approximately 10:30am revealed: The policies provided at the agency level are being updated and the bereavement program is being modified to provide "consistency." The electronic medical record is also being updated to include a new post death bereavement risk assessment, which is "not live yet" and a new bereavement care plan, which "went live October 20, 2023," per Director of Support Services. All parties confirmed that employee training has begun, and employees have been instructed to use the "Regional Bereavement Program Quick Resource Guide" as transition continues. Program Director provided staff attendance verification for meetings dated 3/29/23, starting at 9:25am and ending at 1:59pm, titled: "Heritage Hospice and Bereavement."
Review of agency "Regional Bereavement Program Quick Resource Guide" on 1/3/24 at approximately 10:00am revealed:
1. Bereavement Program and Goal ... d. Bereavement Support Procedures in Chronological Order: ... Death of the Patient...5-10 Days Post Death LOW RISK, Local Branch Bereavement SC/SW (Spiritual Coordinator/Social Worker) Responsibility, -Initial Bereavement Assessment -Care Plan -Clinical Note -Condolence Care -Explanation and education of resources to include the Bereavement Resource Portal ... One Month Post-Death -Mailing from Care Hospice, One to Two Months Post Death -Arbor Day Certificates ... Provided by Care Hospice, Three Month Post-Death -Mailing from Care Hospice, Six Month Post-Death -Mailing from Care Hospice, Nine Month Post-Death -Mailing from Care Hospice, Eleven Month Post-Death -Mailing from Care Hospice, ..."
Review of CR on 1/5/24 between 10:15am and 3:00pm and on 1/8/24 between 9:00am and 1:30pm revealed:
CR3, start of services 5/22/23, time period reviewed 11/18/23-12/19/23, and bereavement period 12/19/23-1/5/24. CR documented low bereavement risk per initial bereavement assessment. Patient death documented 12/19/23. Clinical note dated 1/2/24 documented condolence card sent., 14 days post-death. Post-Death Bereavement Assessment documented 1/5/24, 17 days post-death.
CR9, start of services 3/25/23, time period reviewed 3/25/23-5/5/23, and bereavement period 5/5/23-1/8/24. CR documented low bereavement risk per initial bereavement assessment. Patient death documented 5/5/23. No documentation of Post-Death Bereavement Assessment, condolence card, or 1, 1-2, 3, 6, or 9 month mailings.
CR10, start of services 8/3/23, time period reviewed 8/3/23-8/22/23, and bereavement period 8/22/23-1/8/14. CR documented low bereavement risk per initial bereavement assessment. Patient death documented 8/22/23. Bereavement Care plan effective date 9/27/23 35 days post-death. No documentation of Condolence card or 1, 1-2, or 3 month mailings.
Interview with Program Director on 1/9/24 at approximately 11:00am confirmed missing documentation in bereavement records CR9 & CR 10.
Exit interview with Program Director, Clinical Directors, Administrative Manager, Administrative Assistant, and 8 members of the regional team linked in on a call confirmed findings.
Plan of Correction:What action will we take to correct the deficiency cited? New policies were written to implement the Bereavement Program Quick Resource Guide as the policies for Care Hospice / Heritage Hospice on January 8, 2024, to be taken to the Governing Body Meeting for approval February 13, 2024. Policy will be taken to QAPI meeting in February 2024 as well.
Who is responsible to implement the corrective action? Compliance Department of Care Hospice and Program Director
When will the corrective action be implemented? Policies will be approved and implemented immediately upon approval by Governing Body. Program Director will receive and submit Governing Body Minutes as evidence for POC to QAPI in February 2024.
What is the monitoring process we will put into place to ensure implementation and effectiveness of this corrective action plan? QAPI committee will review and approve new policy in next QAPI Meeting in February 2024 for 100% compliance.
Clinical Directors or designee will audit 100 % of deceased patients weekly x 3 months. Audits to include adherence to timeline and processes as specified by Care Hospice policy.
Once 95% documentation compliance is met and maintained for 3 consecutive months, 20% of patient charts will be audited monthly, for a continued documentation compliance of 95% for 2 additional consecutive months. 1:1 education will be provided to any nursing staff not meeting thresholds.
The agency will continue the review as part of its quality assurance and performance improvement (QAPI) program and will be reported quarterly to the corporate governing body's compliance committee.
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 agency contracts and clinical records (CR), the agency failed to ensure contracted services were provided per written agreement for two (2) of two (2) clinical records reviewed involving therapy services. (CR 2 & 6)
Findings included:
Review of CR2 on January 5, 2024, at approximately 10:15am revealed: start of services 6/30/2022, benefit period reviewed 5/26/23-7/6/23 and bereavement period from 7/6/23-1/5/23. CR contained physician signed order for physical therapy (PT) evaluation dated 6/1/23. Clinical note in record dated 6/7/23 noted "PT eval to be done 6/8." Clinical note dated 6/9 stated "PT eval done." PT scanned to agency from contracted therapist dated 6/8/23. Pt eval conducted 7 days (168 hours) after ordered. No documentation in clinical record of necessity or request for delayed evaluation. Page 1 of 2 of document largely illegible as scanned dark and writing unable to be read.
Review of CR6 on January 8, 2024, at approximately 2:00pm revealed: start of services 7/19/2023, time period reviewed 10/17/23-1/8/24. CR contained physician signed order for speech therapy (ST) evaluation dated 10/25/23. No evidence in clinical record of completion of ST evaluation.
Review of contracts for therapy services on January 3, 2024, at approximately 10:00am revealed:
PHYSICAL AND OCCUPATIONAL THERAPY SERVICES AGREEMENT, THIS PHYSICAL THERAPY and OCCUPATIONAL THERAPY SERRVICES AGREEMENT ("Agreement") is made and entered into this 12th day of July, 2022 (the "Effective Date") by and between HERITAGE HOSPICE its subsidiaries and affiliates ("Hospice") with its principal place of business at 2400 Leechburgh Rd. Bldg 300, New Kensington PA 15068 and Complete Therapy Services, ("Provider") ... AGREEMENT ...1. ... 1.3 Provider and its Professionals agree to provide the Arranged Services to Hospice Patients within twenty-four to seventy-two (24-72) hours of written or oral request by Hospice through its duly authorized representatives. If provider is unable to provide the Arranged Services to Hospice Patients within 24-72 hours, Provider agrees to immediately notify Hospice that there shall either be a delay or an inability to provide the requested services..."
HOSPICE SERVICE AGREEMENT, This agreement (hereinafter referred to as "Agreement") is made and entered into this 2nd day of May 2013 (the "Effective date"), between HERITAGE HOSPICE and (hereinafter referred to as "Hospice"), and FOX REHABILITATION SERVICES, LLC-PA (hereinafter referred to as "Fox") ... Article III - Hospice Responsibilities, Hospice shall: ... C. Request Fox to provide Fox Staff for Fox Services. These requests shall be made by telephone in accordance with physician's order ..."
Exit interview with Program Director, Clinical Directors, Administrative Manager, Administrative Assistant, and 8 members of the regional team linked in on a call confirmed findings.
Plan of Correction:What action will we take to correct the deficiency cited?
Program Director will provide 1 education under L0652
1) Education from the Program director to all contract services to ensure that all requests for services of Physical, Occupational or Speech Therapy will be completed within 24-72 as stated on the contract.
Clinical Directors will track all orders for contract services when they are ordered to ensure they are following contract and that documentation is received.
Who is responsible to implement the corrective action?
Program Director- education of contract staff/Clinical Directors- tracking of contract referrals /educate nursing staff on following up with contract providers for coordination of care.
When will the corrective action be implemented? Feb 1, 2024
What is the monitoring process we will put into place to ensure implementation and effectiveness of this corrective action plan?
Clinical Directors/Designee will Audit and Track 100% of ordered contracted services to ensure compliance of documentation and to ensure that contracted services are completed for the patient in a timely manner. Clinical Director or designee will use tracking form to document date of referral, date of actual service, Communication between Clinical Director and RNCM, RNCM documentation of the contracted visit, and documentation is received from Contracted Service. The audit and tracking of 100% of ordered contracted services will be ongoing for the purpose of ensuring compliance.
The agency will continue the review as part of its quality assurance and performance improvement (QAPI) program and will be reported quarterly to the corporate governing body's compliance committee.
Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey completed January 9, 2024, Heritage Hospice 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 re-licensure survey completed January 9, 2024, Heritage Hospice was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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