Initial Comments:Based on the findings of an unannounced onsite hospice Medicare recertification survey completed 3/4/24 through 3/7/24, Connections Life Care., 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 unannounced onsite hospice Medicare recertification survey completed 3/4/24 through 3/7/24, Connections Life Care., was found 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:
418.54(c)(6) STANDARD
CONTENT OF COMPREHENSIVE ASSESSMENT
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[The comprehensive assessment must take into consideration the following factors:]
(6) Drug profile. A review of all of the patient's prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy. This includes, but is not limited to, identification of the following:
(i) Effectiveness of drug therapy
(ii) Drug side effects
(iii) Actual or potential drug interactions
(iv) Duplicate drug therapy
(v) Drug therapy currently associated with laboratory monitoring.
Observations:
Based on review of policies/procedures, clinical record (CR) reviews and interview with the director the agency failed to ensure the comprehensive assessment included a review of all of the patient's prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy. This includes, but is not limited to, identification of the following: (i) Effectiveness of drug therapy (ii) Drug side effects (iii) Actual or potential drug interactions (iv) Duplicate drug therapy (v) Drug therapy currently associated with laboratory monitoring for (10) ten of (10) clinical records reviewed.
Review of policy Medications Profile on 3/6/24 at 1:00 PM states, "4. The patients medication profile review includes but is not limited to: b. monitoring medication effectiveness, actual or potential medication-related effects and untoward interactions...f. identifying duplicate drug therapy and drug therapy associated with laboratory monitoring."
Review of clinical records on 3/5/24 from 11:00 AM through 3:00 PM &; 3/6/24 from 12:00 PM though 2:00 PM revealed the following:
CR#1 Start of care 2/19/24, the patient's medication profile review did not include identifying effectiveness of drug therapy, duplicate drug therapy and drug therapy associated with laboratory monitoring.
CR#2 Start of care 2/1/24, the patient's medication profile review did not include identifying effectiveness of drug therapy, duplicate drug therapy and drug therapy associated with laboratory monitoring.
CR#3 Start of care 2/20/24, the patient's medication profile review did not include identifying effectiveness of drug therapy, duplicate drug therapy and drug therapy associated with laboratory monitoring.
CR#4 Start of care 3/19/22, the patient's medication profile review did not include identifying effectiveness of drug therapy, duplicate drug therapy and drug therapy associated with laboratory monitoring.
CR#5 Start of care 7/28/23, the patient's medication profile review did not include identifying effectiveness of drug therapy, duplicate drug therapy and drug therapy associated with laboratory monitoring.
CR#5 Start of care 2/19/24, the patient's medication profile review did not include identifying effectiveness of drug therapy, duplicate drug therapy and drug therapy associated with laboratory monitoring.
CR#6 Start of care 4/25/23, the patient's medication profile review did not include identifying effectiveness of drug therapy, duplicate drug therapy and drug therapy associated with laboratory monitoring.
CR#7 Start of care 10/10/22, the patient's medication profile review did not include identifying effectiveness of drug therapy, duplicate drug therapy and drug therapy associated with laboratory monitoring.
CR#8 Start of care 6/22/23, the patient's medication profile review did not include identifying effectiveness of drug therapy, duplicate drug therapy and drug therapy associated with laboratory monitoring.
CR#9 Start of care 12/6/23, the patient's medication profile review did not include identifying effectiveness of drug therapy, duplicate drug therapy and drug therapy associated with laboratory monitoring.
CR#10 Start of care 11/19/21, the patient's medication profile review did not include identifying effectiveness of drug therapy, duplicate drug therapy and drug therapy associated with laboratory monitoring.
Interview with the director during the clinical record reviews confirmed the above findings
Plan of Correction:Action: All patient medication records reviewed by the Director of Clinical Services. The records updated to reflect the five indicators listed on 05/02/2024.
Training: Director of Clinical Services trained on regulation 418.54 Comprehensive Assessment must include the five indicators.
Ongoing: The Comprehensive Assessment will be reviewed by the Director of Clinical Services on admission and recertification to ensure medication safety is being monitored. This will Also be reviewed every 14 days at the IDT meeting with the IDT team Starting 05/02/2024.
Regional Director will be responsible for this Plan of Correction.
418.56(c)(2) STANDARD
CONTENT OF PLAN OF CARE
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[The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following:]
(2) A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs.
Observations:
Based on review of policies/procedures, clinical record (CR) reviews and interview with the director the agency failed to ensure a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs for (6) six of (10) clinical records reviewed CR# 1, CR#2, CR#4, CR#5, CR#6, CR#7
Review of policy Plan of Care on 3/6/24 at 2:00 PM states, "1. The patient's plan of care specifies the care and services necessary to meet the needs of the patient/family as identified in the initial, comprehensive and updated assessment of the patient."
Review of clinical records on 3/5/24 from 11:00 AM through 3:00 PM &; 3/6/24 from 12:00 PM though 2:00 PM revealed the following:
CR#1 Start of care 2/19/24, the patient's plan of care failed to include a duration for skilled nursing and social work visits.
CR#2 Start of care 2/1/24, the patient's plan of care failed to include a duration for skilled nursing, home health aide and social work visits.
CR#4 Start of care 3/19/22, the patient's plan of care failed to include a duration for skilled nursing, chaplain and social work visits.
CR#5 Start of care 7/28/23, the patient's plan of care failed to include any visits to be provided to the patient.
CR#6 Start of care 4/25/23, the patient's plan of care failed to include a duration for skilled nursing &; home health aide visits.
CR#7 Start of care 10/10/22, the patient's plan of care failed to include a duration for skilled nursing &; home health aide visits.
Interview with the director during the clinical record reviews confirmed the above findings
Plan of Correction:Action: The Director of Clinical Services reviewed all patient records to ensure records reflect the frequencies and duration of all disciplines. All orders were completed ad signed. This will be completed by 05/02/2024 by the IDT team.
Training: Director of Clinical services and nursing team will be educated on regulation 418.5 Plan of Care, by 05/02/2024.
Ongoing: The Plan of Cares will be reviewed every 14 days by the Director of Clinical Services and the IDT team during the IDT meeting starting 05/02/2024.
The Regional Director will be responsible for this Plan of Correction.
418.56(e)(2) STANDARD
COORDINATION OF SERVICES
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[The hospice must develop and maintain a system of communication and integration, in accordance with the hospice's own policies and procedures, to-]
(2) Ensure that the care and services are provided in accordance with the plan of care.
Observations:
Based on review of policies/procedures, clinical record (CR) reviews and interview with the director the agency failed to ensure that care and services are provided in accordance with the plan of care for (8) eight of (10) clinical records reviewed (CR#1, CR#2, CR#4, CR#5, CR#6, CR#7, CR#8, CR#10).
Review of policy Plan of Care on 3/6/24 at 2:00 PM states, "1. The patient's plan of care specifies the care and services necessary to meet the needs of the patient/family as identified in the initial, comprehensive and updated assessment of the patient."
Review of clinical records on 3/5/24 from 11:00 AM through 3:00 PM &; 3/6/24 from 12:00 PM though 2:00 PM revealed the following:
CR#1 Start of care 2/19/24, the patient's plan of care failed to include a duration for skilled nursing and social work visits.
CR#2 Start of care 2/1/24, the patient's plan of care failed to include a duration for skilled nursing, home health aide and social work visits.
CR#4 Start of care 3/19/22, the patient's plan of care failed to include a duration for skilled nursing, chaplain and social work visits.
CR#5 Start of care 7/28/23, the patient's plan of care failed to include any visits to be provided to the patient.
CR#6 Start of care 4/25/23, the patient's plan of care failed to include a duration for skilled nursing &; home health aide visits.
CR#7 Start of care 10/10/22, the patient's plan of care failed to include a duration for skilled nursing &; home health aide visits.
CR#8 Start of care 6/22/23, the patient's plan of care included chaplain visits twice a month. There was no documentation that the chaplain made a visit to the patient in the month of January 2024.
CR#10 Start of care 11/19/21, the patient's plan of care included chaplain visits twice a month. There was no documentation that the chaplain made a visit to the patient in the month of January 2024.
Interview with the director during the clinical record reviews confirmed the above findings
Plan of Correction:Action: All patient's Plan of Care have been reviewed by the Director of Clinical Services to reflect the coordination of services with Hospice Aide, Skilled Nursing, Social Worker, and Chaplin services. This review will be completed by 05/02/2024 by the Director of Clinical Services.
Training: The Director of Clinical Services, Hospice Aide, Social Worker and Chaplin will be educated on regulation 418.56 Coordination of Services by 05/02/2024.
Ongoing: The Director of Clinical Services and the IDT team will review the Plan of Care to ensure the coordination of care is maintained. This will be reviewed every 14 days during the IDT meeting by the Director of Clinical Services and the IDT team starting 05/02/2024.
The Regional Director will be responsible for this 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 upon review of agency policy, home visits, and interview with the director, the agency failed to show evidence that infection control measures were followed for bag technique for one (1) one of (3) three home visits observed. (observation #3, employee #13).
Review of agency policy on 3/7/24 at 11:00 AM titled " Clinical Bag Technique" stated " Procedure 2. Select a flat secure work surface to place bag and set up work area. Use discretion and consideration when placing bag on patient's furniture, Never place bag on the floor."
Observation during home visit conducted on 3/7/24 at approximately 10:15AM revealed EMP # 13 had the clinical bag on the patient's floor
Interview with the director on 3/7/24 at approximately 11:00 AM confirmed above findings.
Plan of Correction:Action: All clinical staff, Skilled Nursing, Hospice Aide, Social Worker, and Chaplin, have reviewed and signed the new bag technique policy, this will be completed by 05/02/2024.
Training: The Director of Clinical services and the clinical team will be educated on regulation 418.60, Prevention by 05/02/2024.
Ongoing: The Director of Clinical Services will make on site visits weekly starting to ensure compliance with the bag technique policy. The Director of Clinical Services will ensure all new employees are educated on the bag technique policy. Employee charts will be reviewed monthly for compliance by the Director of Clinical Services starting 05/02/2024.
The Regional Director will be responsible for this Plan of Correction.
418.76(h)(1)(i) STANDARD
SUPERVISION OF HOSPICE AIDES
Name - Component - 00
(l) A registered nurse must make an on-site visit to the patient's home:
(i) No less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. The hospice aide does not have to be present during this visit.
Observations:
Based on a review of policies, clinical records (CRs), and interview with the director, the hospice failed to ensure that a registered nurse documented an on-site visit to the patient's home no less frequently than every 14 days (two weeks) to assess the quality of care and services provided by the home hospice aide (HHA) for three (3) of four (4) CRs reviewed having home health aide services. (CR #8, CR#9, CR#10)
Review of policy, "Hospice Aide Supervision" on 3/7/24 at approximately 1:00 PM states, "Hospice aides are supervised by a registered nurse in a manner and frequency that assures the safety of patients and the quality of aide services provided. n 1. A registered nurse makes an on site visit to the patient's home no less than every 1 days to ensure that the services ordered by the IDG and provided by the hospice aide are meeting the patient's need."
Review of clinical records on 3/5/24 from 11:00 AM through 3:00 PM &; 3/6/24 from 12:00 PM though 2:00 PM revealed the following:
CR#8 Start of care 6/22/23. Certification period reviewed 1/18/24-3/17/24. The registered nurse conducted skilled nursing visits on 1/19/24, 1/23/24, 1/26/24, 1/29/24, 2/2/24, 2/6/24, 2/9/24, 2/12/24, 2/14/24, 2/16/24, 2/20/24, 2/23/24 &; 2/26/24. There was no documentation of a hospice aide supervision from 1/19/24 through 2/26/24
CR#9 Start of care 12/6/23. Certification period reviewed 12/6/23 through March 4, 2024. The registered nurse conducted skilled nursing visits on 2/1/24, 2/5/24, 2/8/24, 2/12/14, 2/15/24, 2/19/24 &; 2/21/24. There was no documentation of a hospice aide supervision from 2/1/24 through 2/21/24
CR#10 Start of care 11/19/21. Certification period reviewed 1/8/23 through 3/7/24. The registered nurse conducted skilled nursing visits on 2/1/24, 2/5/24, 2/7/24, 2/9/14, 2/11/24, 2/13/2, 2/15/24, 2/17/24, 2/19/24, 2/22/24, 2/25/24, 2/28/24 &; 3/1/24. There was no documentation of a hospice aide supervision from 2/1/24 through 2/21/24 3/1/24
Interview with the director during the clinical record reviews confirmed the above findings
Plan of Correction:Action: The Director of Clinical Services has trained all RN's on regulation 418.76, Hospice Aide supervision. This training will be completed by 05/02/2024.
Training: The Director of Clinical Services, has added the supervisory visit documentation into the electronic charting template Wellsky. The Director of Clinical Services will train all RN's on documentation of supervisory visits by 05/02/2024 and frequency of said visits (must occur at least every 14 days).
Ongoing: The Director of Clinical Services will review the supervisory visit documentation weekly for compliance starting 05/02/2024.
The Regional Director will be responsible for this Plan of Correction.
418.100(g)(1) STANDARD
TRAINING
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(1) A hospice must provide orientation about the hospice philosophy to all employees and contracted staff who have patient and family contact.
Observations:
Based on review of policies and procedures, personnel files and interview with the director, the hospice failed to provide orientation about the hospice philosophy to all employees and contracted staff who have patient and family contact for (3) three of (8) eight personnel (PF#4, PF#5, PF#8)
Review of policy Orientation Program on 3/6/24 at 2:00 PM states, "Hospice provides an orientation program intended to ensure that all newly hired employees have the training and competency necessary to perform their jobs effectively. 1. All newly hired employees participate in an orientation program prior to providing patient care or assuming administrative responsibilities. 2. All employees are oriented to: a. the hospice philosophy of care."
Review of personnel files on 3/4/24 at 1:00 PM revealed the following:
PF#4: Date of hire 12/18/23, there was no documentation this employee was oriented to the hospice philosophy of care.
PF#5: Date of hire: 12/12/22, there was no documentation this employee was oriented to the hospice philosophy of care.
PF#8: Date of hire: 2/1/11, there was no documentation this employee was oriented to the hospice philosophy of care.
Interview with the director on 3/4/24 at approximately 2:00 PM confirmed the above findings
Plan of Correction:Action: The Director of Clinical Services has given documented education regarding regulation 418.100, training, to the Hospice Aide, Social Worker and LPN. This will be completed by 05/02/2024 by the Director of Clinical Services.
Training: The Director of Clinical Services will be educated on regulation 418.100, training, to provide hospice orientation program for all current and future employees by 05/02/2024.
Ongoing: The Director of Clinical Services will monitor employee charts monthly for compliance to ensure all trainings/orientation are completed. The Director of Clinical Services will begin the monthly review starting 05/02/2024.
The Regional Director will be responsible for this Plan of Correction.
418.100(g)(2) STANDARD
TRAINING
Name - Component - 00
(2) A hospice must provide an initial orientation for each employee that addresses the employee's specific job duties.
Observations:
Based on review of policies and procedures, personnel files and interview with the director, the hospice failed to provide orientation that addresses the employee's specific job duties for (3) three of (8) eight personnel (PF#4, PF#5, PF#8)
Review of policy Orientation Program on 3/6/24 at 2:00 PM states, "Hospice provides an orientation program intended to ensure that all newly hired employees have the training and competency necessary to perform their jobs effectively. 1. All newly hired employees participate in an orientation program prior to providing patient care or assuming administrative responsibilities. 2. All employees are oriented to: a. the hospice philosophy of care....3. Patient care employees receive orientation appropriate to their job functions."
Review of personnel files on 3/4/24 at 1:00 PM revealed the following:
PF#4: Date of hire 12/18/23, there was no documentation this employee was oriented to the employee's specific job duties
PF#5: Date of hire: 12/12/22, there was no documentation this employee was oriented to the employee's specific job duties
PF#8: Date of hire: 2/1/11, there was no documentation this employee was oriented to the employee's specific job duties
Interview with the director on 3/4/24 at approximately 2:00 PM confirmed the above findings
Plan of Correction:Action: The Director of Clinical Services reviewed the position descriptions with the employees who did not have signed job descriptions in their employee file. The employees will review and sign job descriptions by 05/02/2024.
Training: The Director of Clinical Services has reviewed all employee files for compliance and will train Business Office Manager on regulation 418.100, training/employee files by 05/02/2024.
Ongoing: The Director of Clinical Services will monitor employee files monthly for compliance starting 05/02/2024. The Business Office Manager will ensure all new hires have hospice orientation prior to providing patient care and orientation/job descriptions outlining their job function.
The Regional Director will be responsible for this Plan of Correction.
Initial Comments:Based on the findings of an onsite unannounced hospice agency Medicare recertification and state re-licensure survey completed 3/4/24 through 3/7/24, Connections Life Care., 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 unannounced hospice agency Medicare recertification and state re-licensure survey completed 3/4/24 through 3/7/24, Connections Life Care., was found to be in compliance with the requirements of 35 P.S. § 448.809 (b).
Plan of Correction:
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